(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Perceived social support, social skills, and quality of relationships in bulimic women"

PERCEIVED SOCIAL SUPPORT, SOCIAL SKILLS, AND 
QUALITY OF RELATIONSHIPS IN BULIMIC WOMEN 



BY 
NADINE I. GRISSETT 



A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL 

OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT 

OF THE REQUIREMENTS FOR THE DEGREE OF 

DOCTOR OF PHILOSOPHY 

UNIVERSITY OF FLORIDA 

1991 



Copyright 1991 

by 

Nadine I. Grissett 



To my husband, Sean McCallum, 

whose love, support, and encouragement 

made these past several years 

much more worthwhile. 



111 



ACKNOWLEDGMENTS 

I would first like to express my gratitude to my 
chairperson, Dr. Nancy K. Norvell, who has provided me 
immeasurable inspiration and encouragement throughout my 
graduate career. Her support and faith in my abilities kept 
me going at times when my own confidence ebbed, and 
challenged me to even higher goals, both personally and 
professionally. I would also like to thank my committee 
members, Dr. James Johnson, Dr. Anthony Greene, and Dr. 
Jaquelin Goldman, for their valuable suggestions, support, 
and continued interest in my professional development. In 
addition, I acknowledge Dr. John Kuldau for his time and 
input into this project. Last, but definitely not least, I 
would like to thank my husband, Dr. Sean McCallum, for his 
listening ear and continued support. 



iv 



TABLE OF CONTENTS 

Page 

ACKNOWLEDGMENTS iv 

ABSTRACT vii 

INTRODUCTION 1 

Factors Contributing to the Etiology and 

Maintenance of Bulimia 6 

Social Maladjustment 13 

Social Support and Bulimia 14 

Recent Developments in the Social Support Literature. ... 16 

Social Support and the Stress Process 23 

The Relationship of Stress and Social Support 

in Bui imia 25 

Research Aims and Hypotheses 32 

METHOD 35 

Sub j ects 35 

Measures 3 6 

Procedure 43 

RESULTS 45 

Approach to Data Analysis 45 

Comparison of Groups 47 

Demographic and Descriptive Information 47 

Correlations 47 

Perceived Social Support and Social Interactions 50 

Quality of Relationships 51 

Social Effectiveness and Self-Reported 

Social Competence 52 

Psychopathology 54 

Covariate Analyses 54 

DISCUSSION 65 

The Social Network: Quality and Type of Interactions. .. 66 

Social Competence and Effectiveness 68 

Implications and Conclusions 70 

APPENDIX A QUESTIONNAIRES 80 



APPENDIX B DYADIC EFFECTIVENESS SCALE 98 

APPENDIX C VIDEOTAPED INTERACTION 100 

REFERENCES 103 



Vi 



Abstract of Dissertation Presented to the Graduate School 

of the University of Florida in Partial Fulfillment of 

the Requirements for the Degree of Doctor of Philosophy 

PERCEIVED SOCIAL SUPPORT, SOCIAL SKILLS, AND 
QUALITY OF RELATIONSHIPS IN BULIMIC WOMEN 

By 

Nadine I. Grissett 

May 1991 

Chairperson: Nancy K. Norvell, Ph.D. 

Major Department: Clinical and Health Psychology 

The emerging consensus among investigators of bulimia 
nervosa suggests that this is a multidetermined disorder. 
Biological, sociocultural, personality, and family factors 
appear to contribute to the development and maintenance of 
the bulimic individual's symptoms and psychopathology. 
Several studies have suggested that the relationship between 
bulimics and their environment is impaired. Although social 
maladjustment, lack of perceived social support, and 
distressed interpersonal relationships seem to be important 
risk factors for bulimia, little research has addressed this 
directly. The present study explored specific aspects of 
the bulimic's social support network, as well as individual 
difference variables which might mediate her ability to 
obtain support or to perceive this as adequate. 

Twenty-one bulimic women were matched with twenty-one 
normal controls and completed a number of self-report 

vii 



questionnaires assessing perceived social support, the 
quality of interactions and relationships, and social 
competence, as well as psychopathology. They also 
participated in a videotaped interaction which was rated for 
social effectiveness by observers. It was hypothesized that 
bulimics would report significantly less perceived social 
support, significantly more negative social interactions and 
poorer quality of relationships, and would demonstrate 
significantly poorer social skills. 

Results strongly supported all three hypotheses in that 
bulimic women, as compared to non-eating disordered women, 
reported significantly less perceived social support from 
both friends and family. In addition, they reported 
experiencing less positive interactions, and more negative 
interactions and conflict, particularly with family members. 
Finally, bulimics reported feeling less socially competent 
in a variety of situations and were rated as less socially 
effective by observers unaware of their group membership. 
These differences were not due to the subjects' differing 
levels of psychopathology, although this variable did affect 
the report of perceived social support. These results have 
implications for treatment, suggesting that learning 
communication, coping, and problem-solving skills may be 
particularly important for bulimic women. Future research 
should explore the bulimic's relationships in more detail, 
particularly elements of interpersonal dysfunction, 
conflict, and other aspects of her social support system. 

viii 



INTRODUCTION 

During the past 20 years, bulimia, literally 
meaning "ox hunger," has become an increasingly well- 
known psychophysiologic disorder. This syndrome refers 
to episodes of uncontrollable binge eating followed by 
purging methods such as self-induced vomiting, 
excessive use of laxatives and/or diuretics, fasting, 
and excessive exercise. Although bulimia is an eating 
disorder that is widely believed to be of recent 
origin, attempts to understand and conceptualize 
bulimia date back several hundred years (Stein & 
Laakso, 1988) . Nevertheless, this disorder has 
increased greatly in prevalence during recent years, 
and changes have been made in the symptoms seen as 
constituting the syndrome. 

The contemporary concept of bulimia began in the 
mid-1950' s with descriptions of patients with excessive 
appetite for food and exaggerated hunger, and 
Stunkard's (1959) construct of binge eating among obese 
patients. It was not until the 1970' s, however, that 
bulimia came to be recognized as a distinct clinical 
entity. Researchers and clinicians used a number of 
terms as they sought for a way to describe the symptoms 

of the bulimic syndrome — an abnormal increase in the 

1 



sensation of hunger, compulsive eating (Rau & Green, 
1975) , the dietary chaos syndrome (Palmer, 1979) , 
bulimia nervosa (Russell, 1979), and bulimarexia 
(Boskind-White & White, 1983) . 

These different terms reflect the course of 
developing knowledge about bulimia in the last two 
decades. Bulimic characteristics were initially 
investigated during this time by researchers who noted 
their presence in a number of anorectics (Beumont, 
George, & Smart, 1976; Casper, Eckert, Halmi, Goldberg, 
& Davis, 1980; Pyle, Mitchell, & Eckert, 1981; Russell, 
1979) . Gradually it became obvious that bulimia was in 
many cases a separate disorder, occurring with greater 
freguency among individuals with no prior history of 
eating difficulties (Halmi, Falk, & Schwartz, 1981; 
Hawkins & Clement, 1980; Pyle et al., 1981). 

The third edition of the Diagnostic and 
Statistical Manual was the first to classify bulimia as 
a distinct eating disorder (DSM-III, American 
Psychiatric Association, 1980) . The symptoms required 
for a diagnosis of bulimia were basically consistent 
with the historical concept, including recurrent 
episodes of binge eating, purging, lack of control, and 
affective disturbance. Subsequent research indicated 
that bulimic symptoms are common in both student and 
nonstudent populations, so frequency criteria became 
necessary to distinguish between bulimic symptoms and 



the syndrome of bulimia. As a result, the Work Group 
on Eating Disorders for the DSM-III-R (1987) proposed a 
minimum frequency of binging and purging of twice per 
week for at least three months. This criterion has not 
yet been empirically validated. 

Diagnostic criteria for bulimia in the DSM-III-R 
include: 

A. Recurrent episodes of binge eating (rapid 
consumption of a large amount of food in a 
discrete period of time) . 

B. A feeling of lack of control over eating 
behavior during the eating binges. 

C. The person regularly engages in either self- 
induced vomiting, use of laxatives or diuretics, 
strict dieting or fasting, or vigorous exercise in 
order to prevent weight gain. 

D. A minimum average of two binge eating episodes 
a week for at least three months. 

E. Persistent overconcern with body shape and 
weight . 

Most published epidemiological work has surveyed 

college or high school students, with the resulting 

problems of definition and other problems inherent in 

the use of questionnaires (Mitchell & Eckert, 1987) . 

Early prevalence estimates reported that bulimia 

affects between 8 and 19% of college women (Halmi et 

al., 1981; Pyle, Halvorson, Neuman, & Mitchell, 1986), 

but recent studies based on more restrictive criteria 

suggest that rates of clinically significant bulimia in 

this population are only 1-5% (Cooper, Charnock, & 

Taylor, 1987; Drewnowski, Yee, & Krahn, 1988; Hart & 



Ollendick, 1985; Mitchell & Eckert, 1987; Schotte & 
Stunkard, 1987) . The disorder is much more common 
among female students than it is among working women 
(Hart & Ollendick, 1985) or males (Halmi et al., 1981), 
and appears to occur more frequently in whites than in 
blacks, perhaps due to their higher socioeconomic 
status (Mitchell & Eckert, 1987) . Descriptive studies 
up to this point indicate that bulimics are generally 
single, white, well-educated young women in their 
twenties who begin binge eating in their late teens 
(Boskind-Lodahl & White, 1978; Herzog, 1982; Johnson, 
Stuckey, Lewis, & Schwartz, 1982; Pyle et al., 1981). 
However, further epidemiological studies are needed 
which include samples of both urban and rural groups, 
as well as multiple racial and ethnic groups (Mitchell 
& Eckert, 1987) . Bulimic symptoms often follow a 
period of dieting which may have been prompted by the 
suggestion of friends or family, traumatic events, 
weight gain, increased interest in the opposite sex, or 
identity confusion (Abraham & Beumont, 1982; Gandour, 
1984; Johnson et al., 1982; Pyle et al., 1981). The 
frequency of binge eating and purging may vary 
considerably (Fairburn, 1980; Halmi et al., 1981; Pyle 
et al., 1981; Russell, 1979), although DSM III-R 
criteria now require that an individual engage in this 
behavior at least twice per week to be diagnosed as 
bulimic. 



Bulimia occurs among all weight groups, although 
most bulimics are of normal weight for their height and 
age, or slightly above or below this average (Fairburn, 
1981; Herzog, 1982; Johnson et al., 1982). The 
majority also report a large discrepancy between this 
average or healthy weight, with the desired weight 
significantly lower than the healthy weight (Pyle et 
al., 1981; Russell et al., 1979). In general, bulimia 
is accompanied by negative emotions such as guilt, 
anxiety, and depression (Abraham & Beumont, 1982; Pyle 
et al., 1981). Serious medical complications may also 
arise, including gastrointestinal disturbances, 
hypokalemia (potassium deficiency) , dental decay, 
electrolyte imbalances, dehydration, menstrual 
irregularities, and neurological and cardiac 
abormalities (Abraham & Beumont, 1982; Goode, 1985; 
Pyle et al., 1981; Russell, 1979). 

A large body of research has been generated by 
researchers investigating factors contributing to the 
onset and perpetuation of bulimic behavior. Although 
this literature continues to grow, there is an emerging 
consensus among investigators that bulimia is a 
multidetermined disorder. In order to gain a thorough 
understanding of our knowledge thus far, a number of 
factors must be considered. These include biological 
components, sociocultural factors, and personality and 
family characteristics. 



Factors Contributing to the Etiology 
and Maintenance of Bulimia 

Although the contribution of organic factors to 
the onset and maintenance of bulimia is unclear, 
several lines of evidence suggest that bulimia may be 
closely related to biologically-mediated affective 
disorders (Johnson & Maddi, 1986) . First, many bulimic 
patients report symptoms characteristic of affective 
illness, including fluctuating mood states, low 
frustration tolerance, anxiety, and suicidal ideation 
(Glassman & Walsh, 1983; Hudson, Pope, Jonas, & 
Yergelun-Todd, 1983; Johnson & Larson, 1982; Pyle et 
al., 1981). Second, several studies indicate a high 
incidence of major affective disorder among first- and 
second-degree relatives of bulimic patients (Hudson, 
Laffer, & Pope, 1982; Hudson et al., 1983). In 
addition, biological factors involved in bulimia are 
suggested by the fact that two biological markers for 
depression (the dexamethasone suppression test and the 
thyroid-releasing hormone stimulating test) have 
yielded positive results in bulimic patients with the 
same frequency as in patients with major depression 
(Gwirtsman, Roy-Byrne, & Yager, 1983; Hudson et al., 
1982) . Finally, several double-blind placebo- 
controlled studies of antidepressant pharmacotherapy 
have indicated that this treatment may be effective in 
reducing bulimic behaviors, further supporting 
biological hypotheses (Brotman, Herzog, & Woods, 1984; 



Pope & Hudson, 1982; Pope et al., 1983; Sabine, Yonace, 
Farrington, Barratt, & Wakeling, 1983; Walsh, Stewart, 
Wright, Harrison, Roose, & Glassman, 1982) . However, 
although physiological mechanisms appear to play an 
important role in the pathogenesis of bulimia, research 
results have not been consistent, suggesting that this 
disorder results from a number of environmental and 
personality variables. 

Many researchers have implicated sociocultural 
factors in the etiology and maintenance of bulimia. 
During the past several decades there has been an 
increasing emphasis on the importance and social 
desirability of attractiveness in general and thinness 
in particular. In recent years, social standards for 
women have moved towards an increasingly thin ideal, 
with the mass media placing much more emphasis on what 
an acceptable body should look like, and how to attain 
it through dieting and fitness (Garner, Garfinkel, 
Schwartz, & Thompson, 1980; Striegel-Moore, 
Silberstein, & Rodin, 1986) . Bulimic women seem 
especially susceptible to this cultural ideal, and have 
difficulty distancing their self -expectation from 
society's ideal, often with unhealthy consequences 
(Steiner-Adair, 1986; Striegel-Moore et al., 1986). 
For example, results of one study of adolescent girls 
(Steiner-Adair, 1986) indicated that while all girls 
had a similar ideal of " superwoman , " only those who 



8 

were eating-disordered saw this ideal as consistent 
with their own goals. Females without eating disorders 
reported more modest goals. 

Beauty and thinness are often linked with 
femininity, as is dieting behavior (Gillen, 1981; 
Striegel -Moore et al., 1986). Thinness may also be 
associated with success or personal achievement, and 
for some women, being thin may serve to further their 
success in the professional world and give them a 
competitive edge (Striegel-Moore et al., 1986). The 
pursuit of thinness may be one way for a young woman to 
compete, prove her success and personal accomplishment, 
and demonstrate self-control (Johnson & Maddi, 1986; 
Striegel-Moore et al., 1986). This is intensified by 
the fact that young women today are raised in a world 
of shifting cultural norms and as such are faced with 
many ambiguous and sometimes conflicting role 
expectations (Garner, Garfinkel, & Olmsted, 1983). 
Research indicates that bulimics have difficulty 
establishing a good self -concept, identifying and 
asserting their needs, and developing personal autonomy 
and independence (Baird & Sights, 1986; Dunn & 
Ondercin, 1981) . They tend to feel undifferentiated 
and have low self-esteem, and as such may be especially 
unable to cope with the complex sex role expectations 
of our culture (Grissett & Norvell, 1987; Lewis & 
Johnson, 1985; Timko, Striegel-Moore, Silberstein, & 



Rodin, 1987) . A recent study of female undergraduates 
(Timko et al., 1987) indicated that women who deemed 
socially desirable masculine traits as important for 
themselves, and who felt that many roles were central 
to their sense of self, reported significantly more 
eating disorder symptoms. 

Despite the importance of cultural variables in 
the etiology and maintenance of bulimia, many young 
women today do not develop eating disorders, and as 
such it appears that individual variables must also be 
taken into consideration. Many studies have 
investigated psychopathological and personality 
variables of bulimics which might make them more prone 
to bulimic behavior. Using standardized assessment 
instruments, the psychological profiles of bulimics 
have been compared to normal controls and other patient 
populations such as obese individuals and substance 
abusers. In general, results are fairly consistent, in 
that bulimics frequently obtain elevated scores on a 
number of scales measuring psychiatric disturbance 
(Hatsukami, Owen, Pyle, & Mitchell, 1982; Johnson et 
al., 1982; Pyle et al., 1981; Williamson, Kelly, Davis, 
Ruggiero, & Blouin, 1985) . Generally, they report 
feeling more tense, anxious, depressed, compulsive, 
alienated, and more impaired on measures of life 
adjustment (Dunn & Ondercin, 1981; Johnson & Larson, 
1982; Pyle et al., 1981; Williamson, et al., 1985). 



10 

Results of studies investigating the personality 
characteristics of bulimics have been guite variable, 
but two factors seem to emerge consistently. First, 
bulimics experience considerable affective instability, 
as evidenced by depression, fluctuating moods, anxiety, 
impulsive behavior, and a general feeling of being out 
of control (Dunn & Ondercin, 1981; Johnson & Larson, 
1982; Johnson & Maddi, 1986) . It is not clear whether 
the affective instability precedes or follows the onset 
of bulimic symptoms, but it appears that these 
difficulties are long-standing, and result from both 
biogenetic vulnerabilities and maladaptive parenting 
styles (Johnson & Maddi, 1986) . 

A second prominent personality trait among 
bulimics is low self-esteem (Baird & Sights, 1986; 
Boskind-Lodahl , 1976) . In bulimics, this includes 
several distinctive features. First, they seem to have 
difficulty identifying and expressing internal states, 
which leads them to feel undifferentiated, ineffective, 
and helpless to control these internal states (Bruch, 
1973; Lewis & Johnson, 1984). In addition, bulimics 
are very sensitive to rejection, non-assertive, and 
feel uncomfortable socially (Boskind-Lodahl, 1976; 
Johnson et al., 1982; Pyle et al., 1981; Schneider & 
Agras, 1985) . Finally, bulimics have very high 
expectations of themselves, expriencing shame and guilt 
because of the discrepancy they feel between their 



11 

actual and ideal selves (Goodsitt, 1984; Kohut, 1971) 
which is exacerbated by their bulimic behavior. 

In the search for possible origins of some of the 
bulimics' psychopathology and related difficulties, a 
few studies have investigated family characteristics 
among bulimic patients, most using self-report measures 
of family interaction style. In general, findings have 
been fairly consistent. Compared with normal control 
families, the families of normal weight bulimics use 
more indirect patterns of communication, place less 
emphasis on assertiveness and autonomy, and express 
higher achievement expectations, although they are at 
the same time less interested in political, social, 
cultural, and recreational events (Johnson & Flach, 
1985; Ordman & Kirschenbaum, 1984) . In addition, they 
express more aggression, anger, and conflict, and give 
each other less support and commitment (Johnson & 
Flach, 1985; Ordman & Kirschenbaum, 1984). Compared 
with the families of restricting anorexics, bulimic 
families report greater overall psychopathology, as 
reflected by a higher degree of problems in many areas 
of family interaction, including communication, 
affective expression and involvement, control, and 
social desirability (Garner, Garfinkel, & Olmsted, 
1983) . Several investigators using direct 
observational measures of bulimics' family interaction 
style have reported that compared with normal control 



12 

families, families of bulimic-anorexics were less 
helpful, trusting, nurturing, and approaching, and gave 
more belittling, negative, and contradictory messages 
(Humphrey, Apple, & Kirschenbaum, 1985) . 

Thus it appears that a number of biological, 
sociocultural, personality, and family factors may 
contribute to the etiology and maintenance of bulimia. 
Bulimics seem to have a long history of difficulty 
identifying and modulating their internal affective 
states, which contributes to feelings of helplessness, 
ineffectiveness, and lack of confidence interpersonally 
(Johnson & Maddi, 1986). In addition, bulimics' 
families demonstrate significant psychopathology, are 
disengaged and chaotic, and experience a high degree of 
conflict and life stress. Research findings suggest 
that compared to normal families, bulimic families 
communicate in indirect and contradictory ways, have 
less problem-solving skills, and are less supportive, 
while having higher achievement expectations (Johnson & 
Maddi, 1986) . Growing up in this type of environment 
may exacerbate the bulimic's psychopathology and 
difficulty dealing with her own thoughts and feelings, 
and she is likely to feel increasingly unstable, 
lonely, and unable to cope with life stressors. In 
addition, she probably fails to learn adequate skills 
needed to interact comfortably and confidently with 
others while satisfying her own needs. 



13 

Social Maladjustment 

In light of the research reported above, it is not 
surprising that several researchers have investigated 
the life adjustment of bulimics. Most authors have 
utilized the Social Adjustment Scale-Self Report (SAS- 
SR) (Weissman, Prusoff , & Thompson, 1976) , which 
measures performance over the past two weeks in six 
major areas (work, social and leisure activities, 
relationship with extended family, role as a spouse, 
role as a parent, and membership in the family unit) . 
In a preliminary investigation, Johnson and Berndt 
(1983) found that compared to a community sample, 
bulimics showed significantly poorer adjustment in all 
areas, and their scores were most similar to those of a 
group of alcoholic women. Norman and Herzog (1984) 
found similar results at initial evaluation of bulimics 
and at a one-year follow-up. 

Likewise, in a study comparing bulimic graduate 
students and their non-eating disordered colleagues, 
Herzog, Norman, Rigotti, and Pepose (1986) found that 
bulimics reported significantly more social 
maladjustment in the student, social/leisure, and 
family spheres. Freguency of binge eating and purging 
was associated with degree of social impairment, with 
significant social dysfunction noted on the overall 
scale at a minimum of binge eating/purging freguency of 
once per week. A second study (Herzog, Keller, Lavori, 



14 

& Ott, 1987) comparing bulimic women to matched 
controls on the same measure of social maladjustment 
found very similar results. Sixty-eight percent of the 
bulimic subjects and only 13% of the controls scored 
within the impaired range on one or more of the 
subscales (Herzog et al., 1987). Thus it appears 
bulimic women are significantly impaired across a 
number of areas of social interaction. 

Social Support and Bulimia 

It seems then that the bulimic's difficulties in 
social interactions stem in part from conflicted and 
pathological family relationships, which in turn result 
in social maladjustment in many areas. These findings 
of social maladjustment and the sense of isolation 
reported by bulimics (Silberstein et al., 1986) suggest 
that the interaction between the bulimic and her social 
environment is significantly impaired. One might 
hypothesize that the bulimic individual's social 
difficulties affect her ability to receive adequate 
social supports to cope with stress. However, very few 
studies have directly addressed the role of social 
support in the onset and perpetuation of bulimia. 

In a retrospective study of bulimics and 
anorexics, Slater (1988) explored the relationship 
between ideal and perceived support as reported in 
eating disordered women. Results indicated that larger 
discrepancies between ideal and perceived social 



15 

support from parents and a significant other were 
related to increased eating disorder symptomatology in 
bulimics. Both groups reported receiving less social 
support than they desired from either parent. Bulimic 
subjects also demonstrated strong positive correlations 
between ideal social support and seven of the eight 
subscales on the Eating Disorders Inventory (Garner & 
Olmsted, 1984) . 

In a recent study designed to further investigate 
the relationships among bulimic symptoms, social 
support, and social anxiety and distress, 15 bulimics 
and 15 matched controls were examined for differences 
on measures of social support, psychopathology, and 
social-evaluative anxiety (Slater, Grissett, & Norvell, 
1988) . Results indicated that bulimic women harbor a 
pronounced fear of negative evaluation in social 
situations, and exhibit significantly more 
psychopathology, in that they feel more depressed, 
anxious, inadequate, and alienated from others. In 
addition, although the actual reported amount of social 
support did not differ between groups, bulimic women 
reported significantly lower satisfaction with their 
social support. In fact, this dissatisfaction proved 
to be the best predictor of severity of bulimic 
behaviors . 

These studies suggest that the lack of adequate 
perceived social support and distressed interpersonal 



16 

relationships appear to be important risk factors in 

the development and/or maintenance of bulimia. 

Although bulimic women may have access to a similar 

amount of social support as normals, they are 

nonetheless dissatisfied with this. At this point, a 

number of hypotheses could be proposed as we attempt to 

explore the relationship between social support and the 

bulimic syndrome. However, in order to formulate 

meaningful hypotheses regarding the relationship of 

social support to bulimia, it is first important to 

understand relevant social support literature. 

Recent Developments 
in the Social Support Literature 

The social support literature has grown 

considerably in the past two decades, with a great deal 

of emphasis on the relationship between social support 

and physical and emotional health (Cohen, 1988; Cohen & 

Hoberman, 1983; Kessler & McLeod, 1985). Lack of 

social support has been implicated in the etiology of 

physical illness and prospectively associated with 

higher mortality rates in both healthy and unhealthy 

individuals (Berkman, 1985; Cohen & Wills, 1985; 

Kessler & McLeod, 1985; Wallston, Alagna, DeVellis, & 

DeVellis, 1983) . Perceived availability of support has 

also been shown to protect individuals from the 

psychological impacts of exposure to stressful life 

events and chronic life strains (Cohen & Hoberman, 



17 

1983; Cohen & Wills, 1985; Kessler & McLeod; 1985; 
Wilcox, 1981) . 

A number of studies have directly linked the 
social environment to disease and mortality, but these 
provide little information about the processes by which 
this occurs (Cohen, 1988) . Cohen (1988) reviews 
several psychosocial process models which rely on 
hypothesized links between social support and 
psychosocial and biological processes. Main-effect 
models have focused primarily on links between social 
integration (a structural index of social ties) and 
health, while stress-buffering models have focused on 
the perceived availability of support. Although a 
relatively small amount of literature has been 
concerned with the direct effects of social support on 
illness onset, the majority of research has 
investigated the hypothesis that social support 
protects individuals from the negative consequences of 
stressors (Wallston et al., 1983). Although the 
relationship between social support and life events is 
quite complex, perceived support has been found to 
result in stress-buffering effects (Cohen, 1988) . 

Further complicating the literature are the many 
conceptual, methodological, and theoretical problems 
involved in the study of social support. Thoits (1982) 
suggests that the concept of social support has often 
been poorly conceptualized and operational i zed, perhaps 



18 

leading to confounds between life events and social 
support measures. This may have caused researchers to 
underestimate the value of the main effects of social 
support. Similarly, Abbey, Abramis, and Caplan (1985) 
emphasize the importance of considering the effects of 
both social support and social conflict. 

The vague nature of the social support concept has 
also been heightened when different researchers have 
used similar terms to refer to a disparate set of 
processes, or when others have used different terms 
that refer to basically the same dimensions (Jung, 
1984) . Despite the fact that several researchers have 
proposed taxonomies of the components of social support 
(House, 1981) , studies often fail to assess the 
influence of these different components separately and 
use broad definitions that combine several elements 
(Jung, 1984) . 

The difficulty which researchers have encountered 
in conceptualizing and operationalizing social support 
is evident in the literature by the variability of 
indicators that have been used to measure this 
construct (Barrera, 1986) . In defining social support, 
it is important to realize that the amount of social 
support is not necessarily equal to number of social 
contacts or the size of one's network. Many 
quantitative and structural aspects of social support 
have been investigated, including number of social 



19 

relationships, composition of the social network, 
patterns of interconnectedness among network members, 
and accessibility of network members (Hall & Wellman, 
1985; Henderson, Duncan- Jones , McAuley, & Ritchie, 
1978; Silberfeld, 1978; Tolsdorf, 1976). However, it 
seems that other qualitative aspects may be equally, or 
perhaps more, important in affecting the facilitation 
and interpretation of supportive behaviors and 
contributing to the perception or psychological sense 
of support (Cutrona, 1986; Gottlieb, 1984) . Some of 
the qualitative aspects that have proven to be 
important include such factors as the influence of 
expectations (Gottlieb, 1984) , positive beliefs in the 
benefits of help-seeking (Eckenrode, 1983) , 
environmental factors (Cutrona, 1986) , sociodemographic 
variables (Riley & Eckenrode, 1986) , and personality 
factors such as self-esteem, hardiness, locus of 
control, coping skills, affiliation and autonomy needs, 
and pre-existing levels of social support (Cohen, 
Mermel stein, Kamarck, & Hoberman, 1985; Cohen & Syme, 
1985; Dunkel-Schetter, Folkman, & Lazarus, 1987; 
Eckenrode, 1983; Kobasa & Pucetti, 1983; Lefcourt, 
Martin, & Saleh, 1984; 1.6. Sarason, Levine, Basham, & 
B.R. Sarason, 1983; 1.6. Sarason, B.R. Sarason, & 
Shearin, 1986) . 

Researchers also differ on whether they assess the 
support an individual actually receives, or their 



20 

perception of the support available to them, 
emphasizing the individual's subjective cognitive 
appraisal of their connections to others rather than 
simply the number of supporters or amount of social 
contact (Barrera, 1986; Cohen et al., 1985; 1.6. 
Sarason et al., 1983). This distinction is important 
because perceived and received social support 
instruments often demonstrate different associations 
with other measures such as indices of negative life 
events or mortality risk (B.R. Sarason, Shearin, 
Pierce, & I.G. Sarason, 1987). It appears that 
perceived available support may be an important 
qualitative aspect to consider when researching this 
area, as it is often a more significant predictor of 
symptomatology than merely quantitative measures (B.R. 
Sarason et al., 1987). The perceived availability and 
adequacy of social support is thus an important element 
to be assessed, as it has been consistently linked to 
positive mental and physical health outcomes (Cutrona, 
1986) , and to more positive personal adjustment 
(Pierce, I.G. Sarason, & B.R. Sarason, 1988) . 

Another important consideration which has 
developed recently in the social support literature 
concerns the quality of the relationships which provide 
support. Up until the early 1980' s, researchers had 
almost exclusively studied the social network in terms 
of its positive influences. However, recently there 



21 

has been an explicit recognition that an individual's 
social network often consists of conflicted 
relationships which may be a source of both positive 
and negative interactions (Barrera, 1981; Eckenrode & 
Gore, 1981) . This is congruent with social exchange 
theorists who have long emphasized the fact that social 
relations entail both costs and rewards (Thibaut & 
Kelley, 1959) . 

In a study examining the relative impact of 
positive and negative social interactions on older 
women's well-being, Rook (1984) found that negative 
social interactions were more consistently and more 
strongly related to well-being than positive social 
interactions. Fiore, Becker, and Coppel (1983) 
proposed that when individuals rate their satisfaction 
with their social support, they are actually responding 
with summary assessments made up of both positive and 
negative perceptions of the network. These researchers 
suggested, as did Gore (1978), that individuals 
reporting low satisfaction are experiencing more unmet 
support expectations and are therefore more stressed 
and more symptomatic. Likewise, Brenner and Norvell 
(in press) found that the presence of at least one 
source of consistent problems in the individual's 
network was more predictive of life satisfaction than 
the presence of consistent positive supports. 



22 

Pagel, Erdly, and Becker (1987) confirmed these 
findings in a longitudinal study investigating both the 
helpful (positive) and the upsetting (negative) aspects 
of social networks of spouses caring for a husband or 
wife with Alzheimer's disease. Results showed that the 
care givers • degree of upset with their networks was 
strongly associated with lower network satisfaction and 
increased depression over time. Helpful aspects of the 
network interacted with network upset in predicting 
satisfaction and depression (Pagel et al., 1987). In 
addition, Pierce et al. (1988) found that the quality 
of relationships (perceived positivity and importance 
of personal relationships, as well as conflict) was 
correlated with the perceived availability and adequacy 
of social support. In fact, the quality of 
relationships made a significant contribution to 
personal adjustment which was independent of that made 
by perceived social support (Pierce et al., 1988). 

Some investigators (Henderson et al., 1978) have 
considered the possibility that since perceptions of 
support adequacy are subjectively determined, they may 
merely reflect the individual's level of adjustment or 
depression. Vinokur, Schul, and Caplan (1987) found 
that perception of support was moderately determined by 
the recipients' negative outlook bias and only weakly 
determined by poor mental health (anxiety and 
depression) . However, findings of several other 



23 

studies (Fiore et al., 1983; Pagel et al., 1987) are 
conflicting and have failed to support the hypothesis 
that the perception of support adequacy simply reflects 
the individual's psychological adjustment. These 
researchers found that perceptions of support were not 
merely a function of level of depression (Fiore et al., 
1983) . In fact, after controlling for initial 
depression and initial level of upset with one's social 
network, changes in perception over time predicted 
changes in depression. That is, level of depression 
increased as the degree of upset and dissatisfaction 
with the social network increased (Pagel et al., 1987). 
Social Support and the Stress Process 
As previously stated, perceived availability of 
social support appears to moderate the impact of life 
events on mental and physical health (Cohen, 1988) , and 
may have a direct effect as well (Thoits, 1982) . The 
stress-buffering effect of social support has received 
considerable attention in the literature, and in many 
cases, perceived support appears to be an important 
factor in a complex and interactive stress process. 
Pearlin, Menaghan, Lieberman, and Mullan (1981) propose 
a process of stress including life events, chronic life 
strains, self -concepts, coping, and social supports. 
They hypothesize that life events adversely affect 
enduring role strains, which in turn erode positive 
self -concepts such as self-esteem and mastery. The 



24 

individual is then left especially vulnerable to 
experiencing symptoms of stress, often including 
depression. Thus, according to this model, coping and 
social supports have an indirect effect in that they 
minimize the elevation of depression by preventing the 
deterioration of self-concepts. In other words, 
psychological variables such as personal control and 
self-esteem mediate the stress-buffering effects of 
social support (Pearlin et al., 1981). 

Lazarus and Launier (1978) propose a transactional 
model describing stress as the discrepancy between the 
demands on a person and that person's appraisal and 
evaluations of his or her potential responses to these 
demands. Elliott and Eisdorfer (1982) conceptualize 
the stress process as a series of interactions between 
the individual and the environment, including four 
components (potential stressors, reactions to a 
particular stressor, consequences of the reactions, and 
mediators at each stage of the process) . Other 
researchers (Shinn, Lehmann, & Wong, 1984) have also 
suggested that typical research models of social 
support are overly simple and should consider the 
influences of stressors, psychological distress, 
personal characteristics of recipients, and 
environmental constraints on support, as well as the 
negative consequences of social interactions. 



25 

The Relationship of Stress 
and Social Support in Bulimia 

In the past several years, researchers have begun 

to investigate how stress is related to the etiology 

and maintenance of bulimia. Shatford and Evans (1986) , 

using linear structural relations analysis (LISREL) , 

developed a causal model of bulimia based on a stress 

process comprised of the sources, mediators, and 

manifestations of stress. The sources of stress they 

considered included environmental stressors (life 

events and daily hassles) and psychological status 

(depression, low self-esteem, external locus of 

control, and general mental health) . Mediators of 

stress included methods of coping (active-cognitive, 

active-behavioral, and avoidance) and focuses of coping 

(problem-focused and emotion-focused) . Based on 

previous research reporting behavioral expressions of 

stress such as increased alcohol use, eating, and 

smoking (Pearlin & Schooler, 1978; Billings & Moos, 

1981) , Shatford and Evans (1986) considered bulimia to 

be a manifestation of stress in the vulnerable bulimic 

individual. Their model thus attempted to describe the 

relationships between environmental stressors, 

depression, psychological status, and stress mediators. 

Results indicated that coping skills are an important 

mediator of stress, and that having a high frequency of 

environmental stressors and/or the presence of 

depression or risk for depression, may lead an 



26 

individual to use ineffective coping mechanisms, which 
may in turn result in bulimic behavior (Shatford & 
Evans, 1986) . 

Cattanach and Rodin (1988) recently suggested the 
importance of assessing the role of psychosocial stress 
in bulimia by viewing it as a process which includes 
stimulus and response, as well as appraisal, coping 
processes, control, social supports, personality 
factors, and other intervening variables predisposing 
an individual to experience more stressors or to be 
more reactive to potential stressors. These authors 
present several internal and external mediators which 
affect the nature of an individual • s reactions to 
stressors. Internal mediators include such things as 
coping abilities, expectations, and prior experience. 
A person's perception of the environment and his or her 
appraisal of probable response outcomes and available 
response options are important because they influence 
the selection of a coping response (Lazarus, 1966) . 
Coping styles include problem-focused coping, which is 
intended to manage the situation, and emotion- focused, 
which is aimed at the resulting emotions. Recent 
research indicates that active coping styles reduce the 
effects of potential stressors, and result in better 
adjustment and less depression, while passive coping 
styles are less effective and are associated with 
increased depression and physical illness (Billings & 



27 

Moos, 1984; Coyne, Aldwin, & Lazarus, 1981; Pearlin & 
Schooler, 1978) . In addition, perceived lack of 
control over events has been identified by several 
investigators as an important variable associated with 
increased illness and psychological distress (Cattanach 
& Rodin, 1988) . 

Cattanach and Rodin (1988) also briefly mention 
several variables which have been investigated as 
external mediators between the individual and the 
environment. One of these mediators is social support, 
which may function in a variety of ways, including 
providing protection from the full impact of potential 
stressors and facilitating coping and adaptation 
(Cattanach & Rodin, 1988) . Personality characteristics 
may also mediate the relationship between the 
individual and the environment, and persons with 
certain styles of perceiving their environment may be 
especially vulnerable to certain kinds of stress and 
may respond to stressors differently then others 
(Cattanach & Rodin, 1988) . 

Several of these elements of the stress process 
have been investigated in bulimic patients, and might 
play an important role in the etiology and maintenance 
of bulimia. Studies investigating the number and types 
of potential stressors experienced by bulimics are 
often confounded by their retrospective self -report 
nature, and in general indicate that the events and 



28 

conditions reported are not highly unusual. As such, 
it seems likely that individual intervening variables 
are more important in determining the relationship 
between potential stressors and bulimic symptoms 
(Cattanach and Rodin, 1988) . 

One variable which may mediate between stressors 
and bulimic behavior is an inaccurate perception and 
appraisal of the environment. Several studies have 
indicated that bulimics may have difficulty appraising 
situations accurately, perhaps causing the perceived 
effect of these events to be exacerbated (Cattanach & 
Rodin, 1988; Heilbrun & Bloomfield, 1986). In 
addition, bulimics may perceive themselves as less able 
to cope with stressors (Lehman & Rodin, 1986) . Some 
researchers have suggested that bulimics may lack a 
full repertoire of coping responses from which to 
select (Hawkins & Clement, 1980) , while others report 
that adeguate coping strategies may be available, but 
bulimics are unable to use them skillfully and 
effectively to cope with difficult situations (Katzman 
& Wolchik, 1985). Katzman and Wolchik (1985) found 
that bulimics, as well as binge eaters and depressed 
subjects, generally used passive coping styles (e.g., 
avoid actively confronting problems, manage resulting 
emotions rather than situations) and were unable to 
express their feelings, a combination which has been 
associated with poorer adjustment (Billings & Moos, 



29 

1981) . Shatford and Evans (1986) found that bulimic 
women tend to use avoidance and emotion-focused coping 
responses which are less effective than the problem- 
focused coping responses used by nonbulimic women. 
Their model also suggested that environmental stressors 
and/or depression might lead an individual to use 
ineffective coping mechanisms (Shatford & Evans, 1986) 
and that the bulimic's lack of perceived control may 
lead to binging and purging (Cattanach & Rodin, 1988) . 

Individual difference variables such as 
personality characteristics or mental health may also 
be important mediators in the stress process for 
bulimics. For example, many bulimics evidence 
significant levels of depression (Hudson, Laffer, & 
Pope, 1982; Katzman & Wolchik, 1984; Williamson et al., 
1985) which could affect their situational appraisals 
and may interfere with effective coping responses 
(Katzman & Wolchik, 1984; Lehman & Rodin, 1986). 
Perhaps the bulimic's dysphoric mood impairs her 
appraisal, causing her to perceive more stress than 
others in a similar environment, and thus leading to 
bulimic behavior (Cattanach & Rodin, 1988) . Variables 
such as depression and self-esteem have previously been 
implicated as important factors in the stress process 
(Pearlin et al., 1981). In addition to being a 
precursor of bulimic behavior, these variables may be 
increased by the bulimic symptoms, or may be stressors 



30 

in themselves (Cattanach, & Rodin, 1988; Shatford & 
Evans, 1986) . 

One factor in the stress process which has 
received limited attention in the bulimic literature is 
that of social support. As reported earlier, a number 
of studies indicate that bulimic women are often 
socially maladjusted and feel isolated from others 
(Johnson & Berndt, 1983; Norman & Herzog, 1984; Herzog 
et al., 1987), suggesting that they lack adequate 
social supports to cope with stress. In addition, 
bulimics express significant dissatisfaction with their 
perceived social support, which is strongly related to 
the severity of bulimic symptoms (Slater et al., 1988). 
However, little is known about specific aspects of the 
bulimic's social support system which may be helpful or 
problematic, or which might contribute to her 
dissatisfaction and maladjustment. 

It seems apparent from such research that 
disturbed interpersonal relationships and the lack of 
perceived social support are important components of 
the bulimic syndrome. At this point a number of 
hypotheses might be considered. For example, perhaps 
the bulimic lacks the skills or competence necessary to 
take advantage of available support. Previous research 
has demonstrated the bulimic's considerable fear of 
negative evaluation in social situations, interpersonal 
sensitivity, low self-esteem, and affective instability 



31 

(Johnson & Maddi, 1986; Slater et al., 1988). In 
addition, bulimics appear to be socially maladjusted 
(Herzog et al., 1987; Johnson & Berndt, 1983), 
suggesting that these personality and 
psychopathological characteristics may interfere with 
her ability to use the available social support network 
in a helpful and adaptive manner. On the other hand, 
perhaps certain aspects of the bulimic's social support 
network (e.g., quality of relationships) are 
problematic and result in the failure of this network 
to provide adequate positive support. This hypothesis 
is based on previous research which has demonstrated 
conflicted and chaotic relationships in bulimic 
families (Garner et al., 1983; Humphrey et al., 1984; 
Johnson & Flach, 1985) and the importance of 
considering negative interactions when assessing social 
support (Abbey et al., 1985; Rook, 1984). It may also 
be possible that the bulimic's symptoms and 
psychopathology play an important role in her social 
difficulties, and that this is simply reflected by her 
social maladjustment and dissatisfaction with social 
support. This hypothesis stems from previous research 
suggesting that perhaps perceptions of support adequacy 
are determined by the individual's level of adjustment 
or depression (Henderson, et al., 1978; Vinokur, et 
al., 1987). 



32 

Research Aims and Hypotheses 
Although many of the factors discussed above have 
been suggested as important components of the stress 
process, research investigating these factors with 
bulimic subjects has been minimal. Inadequate social 
support appears to be part of the bulimic's environment 
and may be important in perpetuating the bulimic cycle, 
but virtually no information is available about 
specific aspects of the bulimic's social support 
network or about other individual difference variables 
which may affect the degree to which adequate social 
support is received. The present study explored 
specific aspects of the bulimic's social support 
network, the quality of her interactions within this 
network, and individual difference variables which 
might mediate her ability to obtain support or to 
perceive this as adequate. 

In light of previous research concerning the 
importance of considering different sources of social 
support, the first aim was to investigate the bulimic's 
perceived social support from both family and friends. 
Several researchers have indicated that these sources 
of support are related but separate, valid, and useful 
constructs (Procidano & Heller, 1983; Sarason et al., 
1987) . Procidano and Heller (1983) suggest that the 
distinction between perceived support from family and 
friends is important, in that these two sources appear 



33 

to be differentially related to symptoms of distress 
and psychopathology, as well as to personality 
characteristics such as social competence, anxiety, and 
mood state (Procidano & Heller, 1983) . 

The second aim of the present study was to explore 
both positive and negative aspects of social 
interaction within the bulimic's social support 
network. Social conflict seems to be strongly related 
to psychopathology and network dissatisfaction (Fiore 
et al., 1983; Pagel et al., 1987; Pierce et al., 1988), 
while experiencing positive and important relationships 
is associated with the perception of higher levels of 
support (Pierce et al., 1988). It was hypothesized 
that increased level of negative interactions and poor 
guality of relationships would be highly related to 
bulimic symptoms and thus important to consider when 
exploring the relationship between the social network 
and bulimia. 

In light of previous research emphasizing the 
importance of individual difference variables on the 
perception of social support, this study also aimed to 
explore the relationship of social competence to the 
perception of support and to reported conflicting and 
supportive interactions. Several studies have 
demonstrated a relationship between social skills and 
social support (Cohen et al., 1986; I.G. Sarason et 
al., 1985). Sarason et al. (1985) found that when 



34 

compared to individuals with low levels of reported 
social support, those high in social support were 
significantly greater in self-described and 
experimenter-rated social skills. Similarly, in a 
study by Cohen, Sherrod, and Clark (1986) , social 
skills were found to be prospectively predictive of the 
development of social support and friendship formation. 
Therefore it is important to investigate the 
relationship between social competence and the 
perception of the adeguacy and nature of social 
support . 

With these aims in mind, the study investigated 
the following: 

1. It was hypothesized that bulimics would report 
significantly less perceived social support, as 
compared to normal controls. 

2. It was hypothesized that bulimics would report 
significantly more negative social interactions 
(conflict) and poorer guality of relationships than 
normal controls. 

3. It was hypothesized that bulimics would 
demonstrate significantly poorer social skills than 
controls, as assessed by both self -reported competence 
and observer ratings of social effectiveness. 



METHOD 
Subjects 
Subjects were 42 female undergraduates at the 
University of Florida who participated in the study as 
part of a class requirement or for a payment of $5.00. 
Approximately 800 undergraduates were screened for 
bulimic symptoms using the Bulimia Test (BULIT) (Smith 
& Thelen, 1984) . A research cut-off score of 88 was 
used to identify women endorsing behaviors and 
psychological characteristics similar to those of 
clinically diagnosed bulimics. These women then 
participated in a structured clinical interview, and 
twenty-one who were diagnosed as bulimic by DSM-III-R 
criteria made up the experimental group. Those who did 
not meet DSM-III-R criteria for bulimia nervosa were 
excluded from the study. The 21 women in the 
experimental group were then matched on the variables 
of height and weight with 21 women who served as the 
control group. Matched pairs were within two inches 
and ten pounds of each other. Mean height and weight 
for bulimics were 65 inches and 133 pounds, while 
controls averaged 66 inches and 132 pounds. 



35 



36 

Measures 
The Bulimia Test (BULIT) 

The Bulimia Test (Smith & Thelen, 1984) was used 
to screen subjects for the normal and bulimic samples. 
This 36-item, multiple-choice self-report scale was 
specifically designed to assess bulimic symptoms. 
Construction of the BULIT was based on DSM-III criteria 
and was initially conducted by comparing responses of 
clinically identified female bulimics with non-eating 
disordered female college students on preliminary test 
items. The scale proved to be a good predictor of 
bulimia in both the initial and replication samples. 
Cross validation was then performed using samples of 
bulimic and normal control subjects, and the measure 
was subseguently administered and validated with 
nonclinical populations of undergraduate college women. 
Results indicated that the BULIT is a reliable and 
valid predictor of bulimia in nonclinical populations 
as well. Evidence for construct validity has been 
demonstrated by the BULIT 's high correlation (r=.93, 
P<.0001) with the Binge Scale (Hawkins & Clement, 
1980) , another measure of binging behavior. 
Discriminative validity has been demonstrated by 
significant differences between bulimics (n=20) and 
normal control subjects (n=94) (M=124.0 and M=60.3, 
respectively), t(112)=15.25, p<.0001. In addition, in 
the cross validation studies, the BULIT demonstrated 



37 

high predictive ability, with sensitivity, specificity, 
and positive and negative predictive values all above 
.90. Predictive ability in the nonclinical sample used 
in further validation studies was lower, presumably 
because these subjects 1 scores were less extreme and 
thus more difficult to classify. In these studies, 
sensitivity and specificity were .64 and .89, 
respectively, while the positive and negative 
predictive values were .74 and .84, respectively. 

A cut-off score of 88 was used to screen for those 
women endorsing behavioral and psychological 
characteristics similar to bulimics. Using this 
criterion with a nonclinical population, Smith and 
Thelen report a false negative rate of 0.0 (Smith & 
Thelen, 1984). Similarly, Slater et al. (1988) found 
that 15 of 18 women screened in this manner were 
subsequently diagnosed as clinically bulimic. This 
cut-off provides an efficient way of identifying women 
who display bulimic behaviors which can then be 
verified in a subsequent structured clinical interview 
designed to determine whether they meet DSM III-R 
criteria for bulimia. 
The Perceived Support Scale (PSS) 

The Perceived Support Scale (PSS) (Procidano & 
Heller, 1983) is comprised of two 20-item subscales 
with a dichotomous response (yes-no) format, designed 
to measure the extent to which an individual perceives 



38 

that his or her needs for support, information, and 
feedback are fulfilled by friends (PSS-Fr) and by 
family (PSS-Fa) . In a validation study with 222 
undergraduates, the PSS measures proved to be 
internally consistent (Cronbach's alpha = .88 and .90, 
respectively) , and appeared to measure valid constructs 
that were separate from each other and from network 
measures (Procidano & Heller, 1983) . Separate factor 
analyses with orthogonal factor rotation demonstrated 
each scale to be composed of a single factor (B.R. 
Sarason et al., 1987). Test-retest reliability over a 
1-month period was estimated to be .83 (Procidano & 
Heller, 1983). 

Evidence for construct validity was found, in that 
these two measures were shown to be better predictors 
of psychiatric symptomatology, as measured by the short 
form of the MMPI (Faschinghauer, 1974) , than life 
events or structural characteristics of support 
networks. Subsequent studies supported the 
independence of these constructs by demonstrating their 
differing relationships with various measures of mood 
state, anxiety, psychopathology, and verbal inhibition 
(Procidano & Heller, 1983) . Other findings also 
suggest it is important to distinguish between friends 
and family in the provision of social support (B.R. 
Sarason et al., 1987). 



39 

The Quality of Relationships Inventory (QRI) 

The Quality of Relationships Inventory (QRI; 
Pierce et al., 1988; Pierce, B.R. Sarason, & I.G. 
Sarason, 1989) is a recently developed scale designed 
to assess the quality of the relationships which 
provide social support. The revised version of this 
inventory consists of three scales measuring the 
perceived positivity and importance of primary 
relationships (Depth) , the extent to which the 
relationship is a source of conflict and ambivalence 
(Conflict) , and the perceived availability of social 
support from specific relationships (Support) . Factor 
analysis indicated that these three aspects of 
relationships are independent. Results of a validity 
study with 360 undergraduates indicated that the QRI 
scales significantly contribute to personal adjustment 
independently of the contribution made by social 
support. The QRI was consistently related to perceived 
social support and adjustment measures, and 
discriminated between several categories of 
relationships (Pierce et al., 1989). In the present 
study, subjects completed the QRI for their mother, 
father, closest same-sex friend, and an individual with 
whom they have a romantic relationship (or in absence 
of this, their closest male friend) . 



40 

Social Interactions Scale (SIS) 

A measure similar to that used by Abbey et al. 
(1985) was utilized to assess the qualitative 
perception of negative and positive interactions. 
Abbey et al. (1985) found that their measure of social 
support was related to quality of life, negative 
affect, and psychological well-being, while social 
conflict demonstrated a strong relationship with 
anxiety and depression. In addition, the existence of 
social conflict appeared to be different and more 
distressing than the absence of social support. 

Questions for the SIS were developed to measure 
social support (7 items) and social conflict (10 
items) , and were in the following format: "In the past 
seven days, how much have people in your personal 
life..." (e.g., acted in ways that show you they 
appreciate what you do, treated you with respect, 
argued with you about something, gotten on your 
nerves) . In addition, for each conflict question, 
respondents rated two aspects on a 7-point Likert-type 
scale: 1) how much these occurrences bothered them, 
and 2) how they would explain why these interactions 
occurred. These ratings were designed to explore the 
possible influences of perceived impact and personal 
attributions on the effects of negative social 
interactions . 



41 

Social Competence and Effectiveness 

Self -report . The Social Competence Questionnaire 
(Com-Q) (1.6. Sarason et al., 1985) is a 10-item self- 
report scale designed to tap responses reflecting the 
degree of discomfort in various social situations. 
Com-Q items were rated by the subject on a 4-point 
scale ranging from "not at all like me" to "a great 
deal like me." Example items are "have trouble getting 
to know someone" and "feel confident of my social 
behavior." This measure has demonstrated desirable 
psychometric properties (I.G. Sarason et al., 1985). 

Videotaped interactions . Observer ratings of 
social skills were obtained on videotaped interactions 
in a procedure similar to that used in a study by 
Sarason, Sarason, and Shearin (1986) . In the 
interaction, each subject participated in a 5-minute 
role-play with a female confederate who was unaware of 
the subject's group membership. During this 
interaction, the subject and confederate discussed how 
they might improve their living situation with regard 
to a troublesome third female roommate. The 
confederate was trained to interact in a standardized 
manner with each subject. (See Appendix C for a 
summary of the training instructions) . 

Rating of videotaped interactions . Each tape was 
rated by 3 male and 3 female psychology research 
assistants from the same undergraduate subject pool 



42 

from which the experimental and control subjects were 
drawn. Observers rated subjects using the Dyadic 
Effectiveness Scale (I.G. Sarason et al., 1986) (see 
Appendix B) , which consists of 10 qualities rated on a 
scale from 1 to 6 ("not at all" to "very, very much") . 
(See Appendix C for instructions given to raters.) In 
the original validation study, these ten items as a 
single scale had a reliability of .95 (Cronbach's 
alpha) . The items contribute to three correlated 
subscales: leadership, consideration, and 
attractiveness, which together accounted for 87% of the 
variance and had reliabilities of .96 (Cronbach's 
alpha), .92 (Cronbach's alpha), and .80 (Pearson 
correlation), respectively (Sarason et al., 1986). 

In the present study, observer raters were unaware 
of the subjects' group membership. As in the study by 
Sarason et al. (1986), specific guidelines or training 
were not given to the raters since the purpose was to 
obtain their subjective reactions to the subjects 
rather than to force agreement. Interrater 
reliabilities were computed for all pairs of raters. 
All correlations among raters for total DES scores were 
positive and significant (ranging from .39 to .73). 
Cronbach's alpha for the six raters averaged across the 
10 rated questions was .89; the range was from .88 to 
.96. This was considered more than adequate, given the 



43 

subjective nature of the items 1 content and the lack of 
intensive training in the rating system. 
Psychopatholoqy 

The Symptom Checklist-90 (SCL-90) (Derogatis, 
Rickels, & Rock, 1976) was used to assess 
psychopathology. This measure was developed to examine 
psychiatric symptomatology in outpatients. Each item 
of the SCL-90 is rated on a 5-point scale of distress 
ranging from "not at all" (0) to "extremely" (4) . The 
SCL-90 yields nine subscales of primary symptom 
dimensions and three overall indices of distress. This 
measure has established psychometric qualities, and has 
been used extensively in previous research. Several 
previous studies comparing bulimic women with other 
normal women have indicated significant differences 
between these groups on several scales of the SCL-90 
(Slater et al., 1988; Williamson et al., 1985). 

Procedure 
Once they were screened for group membership 
according to their scores on the BULIT, subjects were 
contacted to arrange a one and one-half hour lab 
session. Upon arrival at the lab, the subject was told 
that this was a study about social support and the 
quality of her social interactions, and was asked to 
sign an informed consent if she wished to participate. 
Height and weight were then verified by the 
experimenter . 



44 

Subjects then completed a packet of questionnaires 
consisting of the Perceived Support Scale (PSS) , the 
Social Support Questionnaire (SSQ) , the Quality of 
Relationships Index (QRI) , the Social Interactions 
Scale (SIS) , Social Competence Questionnaire (COM-Q) , 
and the Symptom Checklist-90 (SCL-90) . Each subject 
then participated in the five-minute videotaped 
interaction. Finally, a diagnostic interview was 
conducted to determine whether or not the subject met 
DSM-III-R criteria for bulimia. Following completion 
of this interview, subjects were debriefed as to the 
nature of the study, given personal feedback regarding 
their scores on the BULIT, and provided with possible 
psychotherapy referrals if the subject desired this 
information. 



RESULTS 
Approach to Data Analysis 
In order to prepare the data for analysis, several 
preliminary data analyses were conducted. Subjects had 
completed the Quality of Relationships Inventory (QRI) 
(including subscales of Support, Depth, and Conflict) 
for four individuals (mother, father, closest same-sex 
friend, and romantic relationship/closest male friend) , 
resulting in 12 separate QRI variables. In order to 
facilitate further analyses to assess group differences 
on the QRI, mother and father ratings on the three QRI 
subscales were collapsed to form "family" variables, 
while ratings of female friends and romantic 
relationships were combined to form "other" variables. 
Thus six combination variables were calculated and 
utilized in further analyses of QRI data: Family 
Support, Family Depth, Family Conflict, Other Support, 
Other Depth, and Other Conflict. Mean values of these 
six variables for the two groups are presented in Table 
1. 

Several other measures were also collapsed to form 
combination variables for use in certain analyses. 
First, the Percieved Support Scale (PSS) measures which 



45 



46 

had been completed for both family and friends were 
combined to create the variable of Total Perceived 
Support. The QRI measures were also further collapsed 
to form the variables of Total Conflict, Total Support, 
and Total Depth. Finally, the Dyadic Effectiveness 
Scale (DES) total was broken down into the three 
subscales of Leadership, Consideration, and 
Attractiveness, which were used in several analyses. 

The initial approach to data analysis involved a 
series of correlational analyses to explore the 
relationships among variables. Several MANOVAs were 
then utilized to test the major hypotheses of group 
differences on measures of perceived support, negative 
interactions, and quality of relationships, as well as 
both self -reported social competence and observer 
ratings of social effectiveness. A MANOVA was also 
used to test for differences between bulimics and 
controls on the measure of psychopathology. 

A final goal of the present study was to further 
understand the role of psychopathology in the bulimic's 
perception of social support, social interactions, and 
quality of relationships. As a result, it was 
desirable to investigate differences between groups on 
the various measures after removing the effects of 
psychopathology. Therefore, group scores on the 
Perceived Support Scale (PSS) , the Social Interactions 
Scale (SIS) , and the Quality of Relationship Inventory 



47 

(QRI) were compared using Multivariate Analysis of 
Covariance (MANCOVA) with overall psychopathology (as 
assessed by the Global Severity Index of the SCL-90) as 
the covariate. Similar MANCOVAs were also utilized to 
test for differences between groups on the measures of 
social competence and effectiveness. 

Comparison of Groups 
Demographic and Descriptive Information 

Results of a Multivariate Analysis of Variance 
(MANOVA) revealed that the mean scores on the Bulimia 
Test (BULIT) for the bulimic and normal control groups 
were significantly different (F(l,35) = 380.73, p < 
.001). The mean BULIT score for the bulimic group was 
109.8 (SD = 13.39), while the mean score for the normal 
group was 43.8 (SD = 5.5). The two groups did not 
differ significantly on any of the demographic 
variables (age, height, weight, grade point average, or 
SAT scores) . Means and standard deviations of these 
variables are presented in Table 2 . 
Correlations 

As an initial step toward understanding the 
relationships among the variables in the present study, 
a number of Pearsons ' product-moment correlations were 
computed. In order to investigate the severity of 
bulimia in relation to the other variables, 
correlations were computed for subjects 1 scores on the 
BULIT, PSS-Friends and PSS-Family, and the SIS 



48 

variables (see Table 3) . Higher BULIT scores were 
significantly negatively associated with amount of 
positive interactions (r = -.38, p < « 05 )/ and 
positively associated with increased negative 
interactions (r = .50, p < .001) and perceived impact 
of this conflict (r = .47, p < .01). In addition, 
perceived social support from family and friends was 
negatively correlated with BULIT scores (r = -.50, p < 
.001 and r = -.45, p < .01, respectively), indicating 
that women scoring higher on the BULIT reported 
significantly less perceived social support from both 
of these sources. 

Correlations were also computed between the BULIT, 
social competence, and the Dyadic Effectiveness Scale 
(DES) total, as well as its three subscales (see Table 
4) . The relationship between BULIT scores and social 
competence approached significance (r = -.29, p = .06), 
as did the correlation between BULIT scores and the DES 
total (r = -.30, p = .06). The relationship between 
self -reported social competence and overall observer 
ratings of social effectiveness also approached 
significance (r = .31, p = .06). 

Finally, correlations were computed between the 
BULIT and the QRI variables (see Table 5) . Significant 
positive relationships were found between BULIT scores 
and measures of conflict with family (r = .60, p < 
.001) and others (r = .31, p = .05), while there was a 



49 

significant negative relationship between severity of 
bulimic symptoms and family support (r = -.33, p < 
.05) . 

Pearsons 1 correlations were also utilized to 
explore the relationships among the PSS and the SIS 
variables. As shown in Table 3, perceived social 
support from both friends and family was significantly 
positively related to positive interactions (r = .61, p 
< .001 and r = .43, p < .01, respectively), and 
negatively related to negative interactions (r = -.52, 
E < .001 and r = -.32, p < .05, respectively), 
indicating that individuals reporting higher levels of 
social support also report more positive interactions 
and less negative interactions. Additional 
correlations indicated that increased social competence 
was related to greater amounts of perceived social 
support from friends and family (r = .44, p < .01, and 
r = .37, p < .05, respectively), as well as more 
positive interactions (r = .38, p < «05) and less 
negative interactions (r = -.36, e < .05). 

In order to better understand the relationship 
between psychopathology and the other measures, 
Pearsons* correlations were also computed between the 
Global Severity Index of the SCL-90 and the BULIT, PSS, 
SIS, and QRI variables (see Table 3) . Higher BULIT 
scores were significantly positively associated with 
increased psychopathology, as indicated by higher 



50 

scores on the GSI (r = .72, p < .001) (see Table 3), 
as well as every subscale. Significant relationships 
were also found between severity of psychopathology and 
several other measures. Women reporting more severe 
psychopathology reported less perceived social support 
from family and friends (r = -.47, p < .01 and r = 
-.40, p < .01, respectively), fewer positive 
interactions (r = -.45, p < .01), more negative 
interactions (r = .46, p < .01), and a stronger impact 
of this conflict (r = .46, p < .01). In addition, 
increased psychopathology was related to increased 
family conflict (r = .60, p < .001). 
Perceived Social Support and Social Interactions 

A MANOVA was used to compare the bulimic and 
control groups on the Perceived Support Scale for both 
friends and family (PSS-FR and PSS-FA) and the Social 
Interactions Scale (SIS) (including measures of 
positive interactions, negative interactions, the 
impact of negative interactions, and attributions for 
these interactions) . Results of this MANOVA 
demonstrated a significant overall group effect 
(F(6,32) = 3.82, p<.01) (see Table 6). Subsequent 
examination of the univariate analyses indicated that 
the bulimic and control groups demonstrated significant 
differences on a number of dimensions. Compared to 
controls, bulimic women reported significantly less 
perceived social support from friends and family 



51 

(F(l,37) = 7.39, E < -01 and F(l,37) = 5.28, £ < «05, 
resEectively) . Although the two groups did not differ 
on the amount of positive interactions experienced, 
bulimics reported significantly more negative 
interactions (F(l,37) = 15.70, e < -001) and indicated 
that this conflict had a greater impact on them 
(F(l,37) = 12.42, £ < .01). In addition, bulimics 
demonstrated a stronger tendency than controls to 
attribute these negative interactions to themselves 
more than to others or to the situation (F(l,37) = 
3.02, e ■ .09), although this result did not attain 
significance. 
Quality of Relationships 

In order to investigate differences between groups 
on the QRI, the three subscales were analyzed using 3 
two (groups: bulimics and controls) by two (sources: 
family and other) ANOVAs. Analysis of the mean support 
scales yielded a significant main effect for source 
(family or other) (F(l,37) = 20.16, p < .001). The 
main effect for the groups approached significance 
(F(l,37) = 3.75, p = «06), and there was no group by 
source interaction. In light of the mean support 
scores, these results indicate that both groups 
reported receiving significantly more support from 
others than from their family, and that there was a 
trend for controls to report more support, although the 
groups did not differ significantly on this variable. 



52 

Examination of the univariate results indicates that 
this trend is primarily due to differences on Family 
Support, which approached significance (F(l,37) = 3.61, 
E = .06) . 

The analyses of the Depth and Conflict scales were 
conducted in the same manner. For depth scores, there 
were no significant differences for source or group 
main effects or for the group by source interaction. 
This indicates that both groups responded similarly in 
their depth ratings of family and others, and did not 
differ in the amount of depth they reported for these 
relationships . 

Results of Conflict scales analyses revealed a 
significant group by source interaction (F(l,36) = 
4.55, p < .05). These results demonstrated that while 
all subjects reported more conflict with family than 
with others, bulimic women did so to a greater extent 
(hence the interaction effect) . Analysis of univariate 
results indicated significant differences between 
groups on the measure of Family Conflict (F(l,36) = 
20.68, p < .001), indicating that the bulimic women 
reported a much greater amount of family conflict. 
Social Effectivess and Self-Reported Social Competence 

Reliability analysis for the ten Dyadic 
Effectiveness Scale (DES) items showed that as a single 
scale, they had a reliability of .98 (Cronbach's 
alpha). The three subscales of Leadership (Items 1, 3, 



53 

4, 5, and 7), Consideration (Items 2, 6, and 8), and 
Attractiveness (Items 9 and 10) , had reliabilities of 
.98 (Cronbach's alpha), .95 (Cronbach's alpha), and .74 
(Pearson's r) . The subscales were highly 
intercorrelated (.75 to .87), and as a result, analyses 
were first performed on the DES total and then repeated 
on the three subscales. 

Multivariate Analysis of Variance (MANOVA) was 
utilized on the Social Competence Questionnaire and the 
DES total in order to examine possible differences 
between groups on self -reported social competence and 
observer ratings of social effectiveness during the 
videotaped interaction. Results demonstrated a 
significant overall group effect (F(4,32) = 2.86, p < 
.05) (see Table 7). Examination of the univariate 
analyses indicated that bulimic women reported 
significantly less social competence than normal 
controls (F(l,35) = 7.52, p < .01), and were rated by 
observers as less socially effective overall (F(l,35) = 
4.58, p < .05). Univariate anayses of the subscales 
indicated that bulimics were rated significantly lower 
than normal controls on the Consideration subscale 
(F(l,35) = 5.83, p <.05), while differences between 
groups on the Leadership scale approached significance 
(F(l,35) = 3.7, p = .06). The means of these measures 
are presented in Table 7. 



54 

Psychopathology 

One aim of the present study was to explore the 
relationship of psychopathology to bulimic symptoms, as 
well as to the measures of perceived social support, 
positive and negative interactions, and the quality of 
relationships. Multivariate Analysis of Variance 
(MANOVA) was used to compare the bulimic and normal 
control groups on the SCL-90 subscales (see Table 8) . 
Results demonstrated a significant difference between 
groups on the Global Severity Index (GSI) , a composite 
score for the Symptom Checklist-90 (SCL-90) which 
measures severity of psychopathology (F(l,40) = 36.71, 
E < .001). Significant differences between the bulimic 
and control groups were also apparent on the Positive 
Symptom Distress Index (PSDI) of the SCL-90, a measure 
of symptomatology intensity (F(l,40) = 33.36, p < 
.001). Univariate analyses of subscale scores 
indicated significant differences between groups on all 
subscales (see Table 8) . 

Covariate Analyses 

One MANCOVA was utilized to compare the bulimic 
and normal control groups on the PSS (including PSS- 
Friends and PSS-Family) and the SIS (including positive 
and negative interactions, impact of negative 
interactions, and attributions for these) . Results 
demonstrated that after controlling for the effects of 
psychopathology, the differences between groups on 



55 

reported negative interactions was still significantly 
different (F(2,36) = 3.96, p = .05). These results 
indicate that the amount of negative interactions made 
a significant contribution to the model over and above 
that of psychopathology. No other significant 
differences were revealed. 

MANCOVAs were also utilized to compare differences 
between groups on the QRI variables (Family Support, 
Other Support, Family Depth, Other Depth, Family 
Conflict, and Other Conflict) . Results of these 
analyses indicated no significant differences on 
Support or Depth scores after controlling for 
psychopathology. However, a significant difference was 
demonstrated between groups in their overall report of 
Conflict (F(l,35) = 4.31, p < .05). Examination of the 
univariate analyses revealed that this difference was 
primarily due to the measure of family conflict. After 
considering the effects of degree of psychopathology, 
group differences on reported family conflict still 
provided a contribution which nearly attained 
significance (F(l,35) = 3.85, p=.058). 

A MANCOVA was also used to test for differences on 
the COMQ and DES total and subscales. Results 
indicated that after controlling for psychopathology, 
the differences between groups on the DES total 
approached significance (F(2,34) = 3.41, p = .07). 
Group differences on the Consideration subscale were 



56 

still significant (F(2,34) = 4.46, p < -05), while the 
Leadership subscale difference approached significance 
(F(2,34) = 2.97. p = .09) . 

Finally, it was desirable to investigate possible 
moderating effects of the variables on the impact of 
psychopathology in predicting whether or not a woman was 
bulimic. In order to test this hypothesis, a series of 
stepwise discriminant analyses were performed, utilizing 
interaction terms formed by multiplying each respective 
variable (PSS-Family, PSS-Friends, Negative 
Interactions, Positive Interactions, Family Support, 
Other Support, Family Conflict, Other Conflict, Family 
Depth, Other Depth, Social Competence, and DES Total) by 
the measure of overall psychopathology (GSI) . These 
were all entered into equations with no more than three 
variables per model (Variable, GSI, and Variable x GSI). 
Results revealed the presence of two interaction terms 
which significantly predicted group membership better 
than either variable alone: Family Conflict x GSI 
(F(l,35) = 33.4, p<.001), and Other Conflict x GSI 
(F(l,39) = 39.7, p<.001). Thus, it appears that the 
self -reported level of conflict exerted a moderating 
effect on the level of psychopathology in predicting 
group membership. Consequently, in the present sample, 
for two subjects reporting equal levels of 
psychopathology, the one with a higher level of conflict 
would more likely be classified as bulimic. 



57 



Table 1 

Univariate Analyses of Repeated Measures ANOVAs on 
Combination Quality of Relationship Inventory 
Variables. 

















Bulimics 


Normals 






M 


SD 


M 


SD 


I 


Family Support 


40.8 


7.6 


44.8 


7.6 


3.61 


Family Depth 


47.8 


8.2 


51.8 


7.4 


2.10 


Family Conflict 


67.3 


11.9 


53.3 


8.7 


20.68* 


Other Support 


47.8 


5.3 


49.2 


2.9 


0.69 


Other Depth 


51.7 


7.3 


51.8 


6.1 


0.00 


Other Conflict 


51.6 


9.6 


46.4 


11.3 


1.93 



*E<.001 



58 



Table 2 

Univariate Analyses of Demographic Variables and 
Bulimia Test (BULIT) Scores . 



MANOVA Overall 
Group Effect 



Bulimia Test 

Age 

Height 

Weight 

SAT Score 

Grade Point 
Average 











F 










57.1* 


Bui 


imics 


Normals 




M 


SD 


M 


SD 


F 


109.8 


13.4 


43.8 


5.5 


380.73* 


20.3 


2.8 


20.3 


2.7 


0.40 


65.0 


4.2 


65.7 


2.6 


0.12 


132.5 


18.7 


131.7 


20.7 


0.07 



1063.3 114.9 1072.1 115.4 



3.1 



0.5 



3.0 



0.5 



0.05 



0.73 



*E<.001 



59 



Table 3 

Pearson Correlations of the Bulimia Test (BULIT) . 
Psychopathology, Perceived Social Support, and Social 
Interactions . 



BULIT GSI PSS-FR PSS-FA POSINT NEGINT IMPACT 
GSI .72*** 
PSS-FR -.45** -.40** 
PSS-FA -.50*** -.47** .39** 
POSINT -.38* -.45** .61*** .43** 
NEGINT .50*** .46** -.52*** -.32* -.59*** 
IMPACT .47** .46** -.42** -.34* -.52*** .88*** 
ATTRIB -.26 -.28 .06 .12 .04 -.18 -.10 



*E<«05 
**p_<.01 
***p_<.001 

Note ; 

GSI =SCL-90 Global Severity Index; 

PSS=Perceived Support Scale (Friends and Family) ; 

POSINT =Positive Interactions from Social Interactions 

Scale (SIS) ; 
NEGINT =Negat ive Interactions from SIS; 
IMPACT = Impact of Negative Interactions; 
ATTRlB=Attribution for Negative Interactions. 



60 



Table 4 

Pearson Correlations of the Bulimia Test (BULIT) , 
Psychopatholocry, Self -Reported Social Competence, and 
Observer Ratings of Videotaped Interactions . 



BULIT GSI COMO PES -TOT DES-L DES-C 



GSI 


.72* 










COMO 


-.29 


-.51* 








DES-TOT 


-.30 


-.24 


.31 






DES-LEAD 


-.28 


-.22 


.31 


.97* 




DES-CONS 


-.31 


-.22 


.26 


.93* 


.87* 


DES-ATTR 


-.28 


-.28 


.31 


.89* 


.86* 



.75* 



*p_<.001 

Note ; 

GSI=SCL-90 Global Severity Index; 
COMQ =Social Competence Questionnaire; 
DES-TOT =Dyadic Effectiveness Scale (DES) Total; 
PES -LEAD =Leader ship Subscale of PES; 
DES-CONS =Consideration Subscale of PES; 
PES-ATTR =Attractiveness Subscale of PES. 



61 



Table 5 

Pearson Correlations of the Bulimia Test (BULIT) , 
Psychopathology, and the Quality of Relationships , 



BULIT GSI FAMSUP FAMDEP FAMCONF OTHSUP OTHDEP 
GSI .72** 

FAMSUP -.34* -.16 

FAMDEP -.26 -.14 .75** 

FAMCONF .60** .60** -.66** -.63** 

OTHSUP -.06 -.16 .18 .11 -.07 

OTHDEP .05 -.07 -.07 -.17 .11 .69** 

OTHCONF .31 .17 -.07 .11 .14 -.12 -.15 



*p<.05 
**p<.001 

Note ; 

GSI =SCL-90 Global Severity Index; 

FAMSUP =Family Support from Quality of Relationships 

Inventory (QRI) ; 
FAMDEP =Family Depth from QRI; 
FAMCONF =Family Conflict from QRI; 
OTHSUP =Other Support from QRI; 
0THDEP =0ther Depth from QRI; 
0THC0NF =0ther Conflict from QRI. 



62 



Table 6 

Univariate Analyses of Perceived Social Support and 
Social Interaction Variables. 



Z 
MANOVA Overall Group 

Effect (PSS & SIS) 3.82** 

Bulimics Normals 

M SD M SD F 

Perceived Social 

Support - Friends 13.1 5.0 17.1 3.4 7.39** 

Perceived Social 

Support - Family 10.9 5.7 15.5 4.9 5.28* 

Positive Interactions 34.4 9.6 39.1 6.8 2.00 

Negative Interactions 34.6 10.5 24.2 9.4 15.70*** 

Impact of Negative 

Interactions 39.1 12.1 27.9 11.6 12.42** 

Attribution for 
Negative 
Interactions 39.8 8.2 44.7 9.7 3.02 



*E<.05 
**p<.01 
***p<.001 

Note : 

PSS =Perceived Support Scale 
SIS=Social Interactions Scale 



63 



Table 7 

Univariate Analyses of Self-Reported Social Competence 
and Observer Ratings of Videotaped Interactions . 



I 
MANOVA Overall 

Group Effect 2.86* 

Bulimics Normals 

M SD M SD F 

Social Competence 

Questionnaire 25.8 6.8 

Dyadic Effectiveness 

Scale (DES) Total 223.1 39.4 

DES Leadership 102.5 24.7 

DES Consideration 72.9 11.2 

DES Attractiveness 47.6 5.5 



*p_<.05 
**p<.01 



30.1 


4.5 


7.52** 


250.2 


31.6 


4.58* 


117.6 


18.5 


3.70 


81.0 


8.6 


5.83* 


51.5 


6.0 


3.29 



64 

Table 8 

Univariate Analyses of SCL-90 Variables . 



MANOVA Overall Group 
Effect (SCL-90) 



Global Severity Index 

Positive Symptom 
Distress Index 

Somaticism 

Obsessive- 
Compulsive 

Interpersonal 
Sensitivity 

Depression 

Anxiety 

Hostility 

Phobia 

Paranoia 

Psychoticism 



Bulimics 

M SD 

1.26 .61 

1.97 .51 
.81 .48 



1.51 



F 
5.51** 
Normals 
M SD F 
.39 .24 36.71** 

1.28 .19 33.36** 
.38 .31 12.07* 



.86 



.62 



.36 19.24** 



1.93 


.84 


.55 


.40 


45.82** 


1.63 


.87 


.59 


.45 


23.83** 


1.00 


.68 


.28 


.23 


21.05** 


1.03 


.80 


.30 


.18 


16.52** 


.50 


.46 


.11 


.14 


13.51** 


1.35 


1.05 


.33 


.38 


17.20** 


1.07 


.65 


.20 


.25 


32.18** 



*p<.01 
**p<.001 



DISCUSSION 

The present study addressed several hypotheses 
concerning the social network and interactions of 
individuals with bulimia. Specifically, the study 
explored various aspects of the bulimic individual's 
social support network, the quality of her interactions 
within this network, and individual difference 
variables which might mediate her ability to obtain 
support or perceive this as adequate. It was 
hypothesized that compared to normal control women, 
bulimic women would report less perceived social 
support, more negative social interactions (conflict) , 
and poorer quality of relationships. In addition, it 
was proposed that they would demonstrate poorer social 
skills, both in terms of self-reported social 
competence and observer ratings of social 
effectiveness. Results support these three hypotheses, 
emphasizing in particular the high level of conflict in 
bulimic individual's relationships and their lack of 
social effectiveness, differences which are significant 
even after considering their level of psychopathology. 



65 



66 

The Social Network: Quality and Type of Interactions 
Results strongly indicate a number of significant 
differences between the social networks and 
interpersonal interactions of women with bulimia and 
non-eating disordered women. Bulimic women perceive 
much less social support in their environment, 
providing additional confirmation of previous research 
findings suggesting that bulimic individuals are 
dissatisfied with their social support network (Slater 
et al., 1989), as well as studies documenting the 
bulimic's sense of isolation and social maladjustment 
(Johnson & Berndt, 1983; Norman & Herzog, 1984; Herzog 
et al., 1987). In order to distinguish between sources 
of support, the present study utilized the Perceived 
Support Scale, an instrument which allows for separate 
examination of support from both family and friends. 
Compared to controls, bulimic individuals reported much 
less support from both of these sources. 

Previous research has indicated that social 
support may function as a mediator between the 
individual and the environment (Cattanach & Rodin, 
1988) . Indeed, the perceived availability and adequacy 
of support is strongly linked to positive mental and 
physical health and personal adjustment (Cutrona, 1986; 
Pierce et al., 1988). In fact, these perceived 
qualities of relationships, rather than objective 
features of the social environment, seem to be the most 



67 

important aspect of social support (Sandler & Barrera, 
1984) . In the present study, overall perceived support 
was strongly related to severity of bulimia and proved 
to be an important predictor of group membership. 
Although it is difficult to determine causal direction 
in the relationship between bulimia and the lack of 
support, this perceived lack may make the bulimic woman 
particularly vulnerable to certain types of stress and 
contribute to the development and maintenance of 
bulimic symptoms. 

Results of the present study also revealed 
significant overall differences between bulimic and 
control women in the type and quality of their 
interactions. First, bulimic women report a much 
higher occurrence of negative interactions. In 
addition, the quality of their relationships is poorer, 
in that they appear to experience much more conflict 
overall, particularly with their family (parents) . The 
level of self-reported conflict was significantly 
higher among bulimic women than controls, and was 
strongly related to the severity of bulimic symptoms. 
This supports previous research which has suggested the 
importance not only of positive aspects of the social 
network, but also highlighted the need to consider the 
contribution of negative interactions and conflict to 
personal adjustment and psychopathology (Brenner, 



68 

Norvell, & Limacher, in press; Pagel et al., 1987; 
Pierce et al., 1988; Pierce et al., 1989). 

Some researchers have suggested that since 
perceptions of support and other aspects of social 
interactions are subjectively determined, they may 
simply be a function of the individual's level of 
psychological adjustment (Henderson et al., 1978). 
Although research findings in this area are 
conflicting, it seems warranted to consider level of 
adjustment when comparing self -report data of this 
nature. In addition, in the present study the bulimic 
and control groups differed significantly on overall 
levels of psychopathology, which suggests that this 
variable deserves special consideration when comparing 
these two groups on other psychological variables. 
Analyses conducted which controlled for the degree of 
psychopathology indicated that the experimental and 
control groups did not differ in their perception of 
support. However, when controlling for 
psychopathology, the two groups did differ 
significantly on several other aspects of their social 
interactions, with bulimic women still reporting higher 
levels of negative interactions, total conflict, and 
family conflict. 

Social Competence and Effectiveness 

Results of the present study indicate that bulimic 
women feel much less socially competent than normal 



69 

control women. They report discomfort and incompetence 
in a variety of social situations, including less 
confidence in their ability to function well socially 
and form close relationships with others, as well as a 
decreased likelihood of engaging in behaviors such as 
seeking out social encounters. Bulimic women therefore 
report both less social support and less social 
competence, consistent with previous evidence 
establishing the relationship between perceived social 
support and self -reported social competence, 
assertiveness, and dating skills (Procidano & Heller, 
1983; B.R. Sarason et al., 1985). 

The results of the present study also suggest that 
observers respond differently to eating disordered 
women than to non-eating disordered individuals. In 
addition to the finding that bulimic women perceived 
themselves as much less socially competent, they were 
also rated as less socially effective compared to 
control group women. Observers rating the taped 
behavior of bulimic women engaging in a five-minute 
interaction perceived them to be less trustworthy 
leaders, worse at problem-solving, and poorer team 
members. Bulimic women were also seen as less skilled 
in their social interaction and rated as less 
considerate and less likely to be a good friend. Thus, 
using two methods to assess the subjects' social 
competence, results strongly suggest that bulimic women 



70 

are less socially competent compared to non-eating 
disordered women. 

Implications and Conclusions 
These results suggest that there are a number of 
aspects of the bulimic individual's social network and 
interactions which are indeed quite different from 
those of non-eating disordered women. Previous studies 
have demonstrated that bulimics' families are more 
pathological in a number of ways (Garner et al., 1983; 
Humphrey et al., 1985; Johnson & Flach, 1985) and that 
bulimics themselves are socially maladjusted in many 
areas of life, including work, social and leisure 
activities, and relationships with family, spouses, and 
others (Herzog et al., 1986; Herzog et al., 1987; 
Johnson & Berndt, 1983) . The present study adds to 
these findings by demonstrating that the bulimic 
individual ' s current interactions and relationships are 
more negative and conflictual than those of non-eating 
disordered women, and that they demonstrate 
significantly poorer social skills. In addition, 
unlike previous studies, the present findings are based 
not only on self-report but also on observer ratings of 
a brief interaction between a bulimic and a non-eating 
disordered woman. Finally, results indicate that these 
differences between bulimic individuals and controls 
are significant even after considering the contribution 
of bulimics* greater psychopathology. 



71 

In light of recent research clarifying the social 
support construct, these findings have important 
implications for understanding the bulimic individual's 
social environment. Several authors have suggested 
that the sense of being loved, valued, and accepted may 
be the most active ingredient of social support 
(Sarason et al., 1987). Pierce (1988) emphasized the 
importance of considering the individual ' s social 
matrix, particularly the nature of personal ties and 
the level of intimacy or feeling of being understood, 
validated, cared for, and closely connected to others. 
Assessing the quality of relationships has proven to 
add significantly to the prediction of adjustment, 
beyond the contribution of general social support 
(Pierce, 1988) . 

The results of the present study support this 
concept, indicating that perceived social support and 
the quality of relationships make independent 
contributions to an individual's level of adjustment. 
The quality of relationships particularly influences 
the effect of social support and contributes greatly to 
bulimic symptomatology. In addition, a high level of 
conflict appears to be even more distressing than a low 
level of social support. This finding is consistent 
with that of Abbey et al. (1985), who found that social 
conflict has an active component that may be more 
distressing than lack of support. This high level of 



72 

conflict and negative interactions in the bulimic 
individual • s social network seems to be quite 
problematic, in that it is strongly related to the 
severity of her bulimic symptoms. 

The social interactions of women with bulimia also 
appear to be greatly affected by their lack of social 
effectiveness. Thus, it is plausible that the bulimic 
individual's self-reported social maladjustment is 
related to her poor social skills. The present study 
provides support for this hypothesis, indicating that 
not only do bulimic women report less social 
competence, but they are perceived as less socially 
effective by others. Results of a recent study by Van 
Buren and Williamson (1988) provide further evidence 
for this finding. These researchers compared married 
bulimic couples to maritally distressed couples and 
normal control couples on measures of relationship 
satisfaction, conflict resolution, and beliefs about 
intimate relationships. Compared to normal controls, 
bulimics in their study demonstrated several 
similarities to the maritally-distressed women who were 
seeking couples therapy. Bulimics experienced a high 
level of dissatisfaction with their marriages, and 
reported deficiencies in conflict resolution skills, 
using few problem-solving skills and frequently 
withdrawing from conflict. In addition, they endorsed 
a belief that their partners, as well as the quality of 



73 

their relationships, cannot change; this belief may 
result in fewer active attempts to resolve conflicts 
(Van Buren & Williamson, 1988) . 

Unlike the present study, which included 
primarily single bulimic women, the bulimic individuals 
in Van Buren and Williamson's study were married and 
the information reported pertained to their spousal 
relationships. However, it seems highly likely that 
these patterns of communication and high levels of 
conflict are common to all of the bulimic woman's 
interactions. Reibel (1989) discusses at length the 
poor communication skills of individuals with bulimia, 
particularly their evasion of direct messages and their 
tendency to do the "right" thing rather than the "real" 
thing. She suggests four misconceptions which may 
hamper communication for these women. First, the 
bulimic individual censors outgoing messages for fear 
that her true feelings such as anger, uncertainty, or 
resentment will not be tolerated. Second, she believes 
that she is "transparent," and as such avoids eye 
contact and does not ask for what she wants, assuming 
others know and are ignoring her desires. Third, the 
bulimic feels the need to protect others from her own 
opinions and feelings, assuming others will judge her 
or are not strong enough to deal with her feelings. 
Finally, she tends to believe that honest communication 
will only destroy relationships. As a result of these 



74 

beliefs, the bulimic individual mistrusts herself and 
others, is prepared for the worst in relationships, and 
feels unable to change anything (Riebel, 1989) . 

These observations suggest that individuals with 
bulimia have very disordered communication patterns, 
which are likely to contribute to their lack of social 
effectiveness, disturbed interpersonal relationships, 
and increased conflict. In addition, it appears that 
the bulimic's lack of social skills or competence may 
indeed interfere with her ability to take advantage of 
available social support, leading to her 
dissatisfaction and perhaps to the exacerbation of her 
bulimic symptoms. Once again, causal direction is 
difficult to determine, but it appears that bulimic 
symptoms frequently arise and are sustained by the 
individual's conflicted, ambivalent relationships and 
lack of intimacy and support. 

Researchers attempting to identify risk factors 
associated with the development of eating disorders 
have implicated several salient factors. These include 
some demographic characteristics, personality 
variables, family dynamics, a constitutional 
disposition, sociocultural influences, and the 
physiological and psychological consequences of severe 
dieting (Shisslak, Crago, Neal, & Swain, 1987). 
Garfinkel, Garner, and Goldbloom (1987) have separated 
these risk factors into three general areas — 



75 

cultural, familial, and individual — and suggest that 
these vary greatly from individual to individual. 
Culturally, the thin female form is idealized and women 
are pressured to perform and please others. Within the 
bulimic individual's family, there may be a family 
history of eating or affective disorders, a 
magnification of cultural attitudes, or family 
relationships which discourage autonomy. The eating 
disordered individual herself may then be particularly 
vulnerable to developing disturbed self-perceptions, a 
lack of autonomy, and personality features and a 
cognitive style which contribute to the onset of 
bulimic symptoms. Garfinkel et al. (1987) suggest that 
these symptoms are then perpetuated by a number of 
factors including the effects of starvation on 
thoughts, emotions, and behavior, the use of bulimic 
symptoms to modulate affect, depression, and secondary 
gain such as the power and sense of specialness derived 
from the bulimia. In addition, lack of social skills 
and friendships may play a powerful role in maintaining 
the self -perpetuating cycle of binge eating and purging 
(Garfinkel, Garner, & Goldbloom, 1987). 

The present study supports this suggestion and 
highlights the fact that bulimic individuals experience 
poor relationships with many people in their lives. 
This appears to be in part a result of their inability 
to communicate honestly and effectively, and to resolve 



76 

conflict appropriately. Interpersonal stress has been 
found to increase the likelihood of binge eating (Van 
Buren & Williamson, 1988) , and indeed binge eating and 
purging may relieve the tension resulting from frequent 
unresolved conflict and dissatisfaction. Bulimic 
behavior may also provide a means of attempting to 
obtain acceptance and intimacy by becoming more 
desirable and attractive. In addition, bulimic 
symptoms may function as an attempt to fill needs for 
self -gratification which are not met by the bulimic 
individual's social network. In any case, it appears 
that a comprehensive treatment program must address the 
bulimic's lack of social effectiveness and poor 
communication and interaction skills which contribute 
to the perpetuation of her bulimic symptoms. 

Limitations of the present study include its 
relatively small sample size and demographically 
restricted sample, which consisted of undergraduate 
women screened for bulimic symptoms and recruited for 
research purposes. In addition, the measure utilized 
to assess the quality of relationships asked subjects 
to report information on four individuals (father, 
mother, closest female friend, and romantic 
relationship/closest male friend) . Although these 
individuals were chosen because they are likely to be 
important in the bulimic's life, this measure may have 
excluded information about relationships with other 



77 

significant individuals. A final limitation of the 
study involves the measures utilized to assess social 
competence and social effectiveness, which were brief 
and consisted of somewhat general items. Bulimic women 
reported overall social competence in a variety of 
situations, but did not directly report their feelings 
and perception of competence during the videotaped 
interaction. In addition, the scale utilized by 
observers to rate bulimics' social effectiveness was 
somewhat limited in the depth and breadth of behaviors 
and verbalizations considered. 

Despite these limitations, results of this study 
have important implications for treatment. Teaching 
communication, coping, and problem-solving skills may 
meet important needs for bulimic women. These skills 
can improve daily functioning, increase their sense of 
self -efficacy, and gradually improve the quality of 
their relationships. This may in turn enable the 
bulimic individual to take advantage of available 
social support and interact more effectively with 
others, thus challenging several factors which 
perpetuate bulimic symptoms. Clear listening and 
reality testing, beginning to understand and convey her 
real messages and needs, learning to comunicate 
directly and honestly — all of these skills could 
decrease the bulimic's need to use food in the 
maladaptive manner of eating disordered women. Further 



78 

treatment studies would be helpful in determining the 
impact and effectiveness of these interventions in 
decreasing bulimic symptoms. 

The results of the present study clearly have 
implications for understanding the social network and 
interpersonal interactions of individuals with bulimia. 
In order to generalize beyond the results from this 
sample, this study should be replicated with a larger 
sample and with community samples that include male 
bulimics, a wider age range, and diversity of 
demographic backgrounds. Future studies might also 
utilize more extensive and in-depth measures of social 
effectiveness to target more specific areas for 
treatment. For example, it would be helpful to obtain 
both quantitative and qualitative ratings of social 
effectiveness in a given situation, including measures 
of nonverbal behaviors (e.g., eye contact and speech 
duration) , the quality of interaction, and the quality 
of problem-solving ability. These measures should be 
obtained not only from observers, but also from 
participants in interactions with bulimics. In 
addition, it would be interesting to have the bulimic 
individuals rate their own social performance during 
the interaction. In this way it would be possible to 
identify the presence of particular behaviors which 
contribute to the social incompetence and interpersonal 
difficulties of eating disordered women, and to learn 



79 

more about the bulimic individual's perceptions, 
thoughts, and feelings during interactions. 

In addition to further exploration of the 
dysfunctional nature of the communication patterns of 
bulimic individuals, studies are also needed to explore 
in more detail the quality of their relationships with 
a variety of significant individuals. It will be 
important to obtain more information about the 
bulimic's intra- and interpersonal conflict and 
dysfunction, as well as other aspects of her social 
interactions which may not have been tapped in the 
present study. This should include further 
investigation of the bulimic individual's social 
support system and her dissatisfaction with this 
support. Only by continuing to increase our 
understanding of these complex factors will it be 
possible to formulate more comprehensive and fine-tuned 
theory, as well as plan more appropriate and effective 
approaches to the treatment of bulimia nervosa. 



APPENDIX A 
QUESTIONNAIRES 



(a) 


(b) 


(c) 


(d) 


+ (e) 


2. I 


(a) 


(b) 


(c) 


(d) 


+ (e) 



BULIT 

Answer each question on the following pages by filling 
in the appropriate circles on the computer answer 
sheet. Please respond to each item as honestly as 
possible; remember, all of the information you provide 
will be kept strictly confidential. 

1. Do you ever eat uncontrollably to the point of 
stuffing yourself (i.e., going on eating binges)? 

Once a month or less (or never) 

2-3 times a month 

Once or twice a week 

3-6 times a week 

Once a day or more 

am satisfied with my eating patterns. 

Agree 

Neutral 

Disagree a little 

Disagree 

Disagree strongly 

3. Have you ever kept eating until you thought you'd 
explode? 

+(a) Practically every time I eat 

(b) Very frequently 

(c) Often 

(d) Sometimes 

(e) Seldom or never 

4. Would you presently call yourself a "binge eater"? 
+(a) Yes, absolutely 

(b) Yes 

(c) Yes, probably 

(d) Yes, possibly 

(e) No, probably not 

5. I prefer to eat: 
+(a) At home alone 

(b) At home with others 

(c) In a public restaurant 

(d) At a friend's house 

(e) Doesn't matter 

6. Do you feel you have control over the amount of food 
you consume? 

(a) Most or all of the time 

(b) A lot of the time 

(c) Occasionally 

(d) Rarely 
+(e) Never 

81 



(a) 


(b) 


(c) 


(d) 


(e) 


8. I 


+ (a) 


(b) 


(c) 


(d) 


(e) 



82 



X 7. I use laxatives or suppositories to help control 
my weight. 

Once a day or more 

3-6 times a week 

Once or twice a week 

2-3 times a month 

Once a month or less (or never) 

eat until I feel too tired to continue. 

At least once a day 

3-6 times a week 

Once or twice a week 

2-3 times a month 

Once a month or less (or never) 

9. How often do you prefer eating ice cream, milk 
shakes , or 

puddings during a binge? 
+(a) Always 

(b) Frequently 

(c) Sometimes 

(d) Seldom or never 

(e) I don't binge 

10. How much are you concerned about your eating 
binges? 

(a) I don't binge 

(b) Bothers me a little 

(c) Moderate concern 

(d) Major concern 

+(e) Probably the biggest concern of my life. 

11. Most people would be amazed if they knew how much 
food I can consume at one sitting. 

+(a) Without a doubt 

(b) Very probably 

(c) Probably 

(d) Possibly 

(e) No 

12. Do you ever eat to the point of feeling sick? 
+(a) Very frequently 

(b) Frequently 

(c) Fairly often 

(d) Occasionally 

(e) Rarely or never 

13. I am afraid to eat anything for fear that I won't 
be able to stop. 

+(a) Always 

(b) Almost always 

(c) Frequently 

(d) Sometimes 

(e) Seldom or never 



83 



14. I don't like myself after I eat too much. 
+(a) Always 

(b) Frequently 

(c) Sometimes 

(d) Seldom or never 

(e) I don't eat too much 

15. How often do you intentionally vomit after eating? 
+(a) 2 or more times a week 

(b) Once a week 

(c) 2-3 times a month 

(d) Once a month 

(e) Less than once a month (or never) 

16. Which of the following describes your feelings 
after binge eating? 

(a) I don't binge eat 

(b) I feel O.K. 

(c) I feel mildly upset with myself 

(d) I feel quite upset with myself 
+(e) I hate myself 

17. I eat a lot of food when I'm not even hungry. 
+(a) Very frequently 

(b) Frequently 

(c) Occasionally 

(d) Sometimes 

(e) Seldom or never 

18. My eating patterns are quite different from eating 
patterns of most people. 

+(a) Always 

(b) Almost always 

(c) Frequently 

(d) Sometimes 

(e) Seldom or never 

19. I have tried to lose weight by fasting or going on 
"crash" diets. 

(a) Not in the past year 

(b) Once in the past year 

(c) 2-3 times in the past year 

(d) 4-5 times in the past year 

+(e) More than 5 times in the past year 

20. I feel sad or blue after eating more than I'd 
planned to eat. 

+(a) Always 

(b) Almost always 

(c) Frequently 

(d) Sometimes 

(e) Seldom, never, or not applicable 



84 



21. When engaged in an eating binge, I tend to eat 
foods that are high in carbohydrates (sweets and 
starches) . 

+(a) Always 

(b) Almost always 

(c) Frequently 

(d) Sometimes 

(e) Seldom, or I don't binge 

22. Compared to most people, my ability to control my 
eating behavior seems to be: 

(a) Greater than other's ability 

(b) About the same 

(c) Less 

(d) Much less 

+(e) I have absolutely no control 

23. One of your best friends suddenly suggests that you 
both eat at a new restaurant buffet that night. 
Although you'd planned on eating something light at 
home, you go ahead and eat out, eating quite a lot and 
feeling uncomfortably full. How would you feel about 
yourself on the ride home? 

(a) Fine, glad that I'd tried the new restaurant 

(b) A little regretful that I'd eaten so much 

(c) Somewhat disappointed in myself 

(d) Upset with myself 

+(e) Totally disgusted with myself 

24. I would presently label myself a "compulsive eater" 
(one who engages in episodes of uncontrolled eating) . 
+(a) Absolutely 

(b) Yes 

(c) Yes, probably 

(d) Yes, possibly 

(e) No, probably not 

25. What is the most weight you've ever lost in one 
month? 

+(a) Over 20 pounds 

(b) 12-20 pounds 

(c) 8-11 pounds 

(d) 4-7 pounds 

(e) Less than 4 pounds 

26. If I eat too much at night I feel depressed the 
next morning. 

+(a) Always 

(b) Frequently 

(c) Sometimes 

(d) Seldom or never 

(e) I don't eat too much at night 



85 



27. Do you believe that it is easier for you to vomit 
than it is for most people? 

+(a) Yes, it's no problem at all for me 

(b) Yes, it's easier 

(c) Yes, it's a little easier 

(d) About the same 

(e) No, it's less easy 

28. I feel that food controls my life. 
+(a) Always 

(b) Almost always 

(c) Frequently 

(d) Sometimes 

(e) Seldom or never 

29. I feel depressed immediately after I eat too much. 
+(a) Always 

(b) Frequently 

(c) Sometimes 

(d) Seldom or never 

(e) I don't eat too much 

30. How often do you vomit after eating in order to 
lose weight? 

(a) Less than once a month (or never) 

(b) Once a month 

(c) 2-3 times a month 

(d) Once a week 

+(e) 2 or more times a week 

31. When consuming a large quantity of food, at what 
rate of speed do you usually eat? 

+(a) More rapidly than most people have ever eaten in 
their lives 

(b) A lot more rapidly than most people 

(c) A little more rapidly than most people 

(d) About the same rate as most people 

(e) More slowly than most people (or not applicable) 

32. What is the most weight you've ever gained in one 
month? 

+(a) Over 20 pounds 

(b) 12-20 pounds 

(c) 8-11 pounds 

(d) 4-7 pounds 

(e) Less than 4 pounds 

X 33. Females only . My last menstrual period was 

(a) Within the past month 

(b) Within the past 2 months 

(c) Within the past 4 months 

(d) Within the past 6 months 

(e) Not within in the past 6 months 



86 



X 34. I use diuretics (water pills) to help control my 
weight. 

(a) Once a day or more 

(b) 3-6 times a week 

(c) Once or twice a week 

(d) 2-3 times a month 

(e) Once a month or less (or never) 

35. How do you think your appetite compares with that 

of most people you know? 

+(a) Many times larger than most 

(b) Much larger 

(c) A little larger 

(d) About the same 

(e) Smaller than most 

X 36. Females only . My menstrual cycles occur once a 
month : 

(a) Always 

(b) Usually 

(c) Sometimes 

(d) Seldom 

(e) Never 



+ represents the most ' symptomatic ■ response and 
receives a score of 5 points 

X denotes questions for which responses are not 
included in the summed BULIT score 



87 



PSS-Fr 



The statements which follow refer to feelings and 
experiences which occur to most people at one time or 
another in their relationships with friends . For each 
statement there are three possible answers: Yes, No, 
and Don't know. Please use the scale provided when 
answering each question, and mark your answers on the 
answer sheet. 

12 3 

Yes No Don't know 

1. My friends give me the moral support I need. 

2. Most other people are closer to their friends than 
I am. 

3. My friends enjoy hearing about what I think. 

4. Certain friends come to me when they have problems 
or need advice. 

5. I rely on my friends for emotional support. 

6. If I felt that one or more of my friends were upset 
with me, I'd just keep it to myself. 

7. I feel that I'm on the fringe in my circle of 
friends. 

8. There is a friend I could go to if I were just 
feeling down, without feeling funny about it later. 

9. My friends and I are very open about what we think 
about things. 

10. My friends are sensitive to my personal needs. 

11. My friends come to me for emotional support. 

12 . My friends are good at helping me solve my 
problems . 

13 . I have a deep sharing relationship with a number of 
friends. 

14. My friends get good ideas about how to do things or 
make things from me. 

15. When I confide in friends, it makes me feel 
uncomfortable . 

16. My friends seek me out for companionship. 

17. I think that my friends feel that I'm good at 
helping them solve problems. 

18. I don't have a relationship with a friend that is 
as intimate as other people's relationships with 
friends. 

19. I've recently gotten a good idea about how to do 
something from a friend. 

20. I wish my friends were much different. 



88 



PSS-Fa 



The statements which follow refer to feelings and 
experiences which occur to most people at one time or 
another in their relationships with their families . 
For each statement there are three possible answers: 
Yes, No, and Don't know. Please use the scale provided 
when answering each guest ion, and mark your answers on 
the answer sheet. 

12 3 

Yes No Don't know 

1. My family gives me the moral support I need. 

2 . I get good ideas about how to do things or make 
things from my family. 

3. Most people are closer to their families than I am. 

4. When I confide in the members of my family who are 
closest to me, I get the idea that it makes them 
uncomfortable . 

5. My family enjoys hearing about what I think. 

6. Members of my family share many of my interests. 

7. Certain members of my family come to me when they 
have problems or need advice. 

8. I rely on my family for emotional support. 

9. There is a member of my family I could go to if I 
were just feeling down, without feeling funny about 
it later. 

10. My family and I are very open about what we think 
about things. 

11. My family is sensitive to my personal needs. 

12 . Members of my family come to me for emotional 
support . 

13. Members of my family are good at helping me solve 
problems . 

14. I have a deep sharing relationship with a number of 
members of my family. 

15. Members of my family get good ideas about how to do 
things or make things from me. 

16. When I confide in members of my family, it makes me 
uncomfortable . 

17. Members of my family seek me out for companionship. 

18. I think that my family feels that I'm good at 
helping them solve problems. 

19. I don't have a relationship with my family that is 
as close as other people's relationships with 
family members. 

20. I wish my family were much different. 



89 



Social Interactions Scale 

In the course of daily living, people's interactions 
with others can be pleasant, helpful, and supportive, 
or they can be a source of conflict and negative 
feelings. Please read each question below, and using 
the answer sheet, mark the number that best reflects 
the social interactions you have had in the past week. 

1. In the past seven days, how much have people in your 
personal life 

acted in ways that show they appreciate you? 

12 3 4 5 6 7 
not at all a great deal 

2. In the past seven days, how much have people in your 
personal life treated you with respect? 

12 3 4 5 6 7 
not at all a great deal 

3. In the past seven days, how much have people in your 
personal life shown you that they cared about you as 
a person? 

12 3 4 5 6 7 
not at all a great deal 

4. In the past seven days, how much have people in your 
personal life given you useful information and 
advice when you wanted it? 

12 3 4 5 6 7 
not at all a great deal 

5. In the past seven days, how much have people in your 
personal life helped out when too many things needed 
to get done or you couldn't do them yourself? 

12 3 4 5 6 7 
not at all a great deal 

6. In the past seven days, how much have people in your 
personal life listened when you wanted to confide 
about things that were important to you? 

12 3 4 5 6 7 
not at all a great deal 



90 



7. In the past seven days, how much have people in your 
personal life visited with you? 

12 3 4 5 6 7 
not at all a great deal 

8. In the past seven days, how much have people in your 
personal life argued with you about something? 

12 3 4 5 6 7 
not at all a great deal 

9. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

10. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

11. In the past seven days, how much have people gotten 
on your nerves? 

12 3 4 5 6 7 
not at all a great deal 

12. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

13 . How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 

something to something to do 

do with me with others or 

the situation 



91 



14. In the past seven days, how much have people in 
your personal life misunderstood the way you 
thought and felt about things? 

12 3 4 5 6 7 
not at all a great deal 

15. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

16. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

17. In the past seven days, how much have people in 

your personal life done things that conflicted with 
your own sense of what should be done? 

12 3 4 5 6 7 
not at all a great deal 

18. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

19. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

20. In the past seven days, how much have people in 

your personal life acted in an unpleasant or angry 
manner toward you? 

12 3 4 5 6 7 
not at all a great deal 



92 



21. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

22. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

23. In the past seven days, how much have people in 
your personal life invaded your privacy? 

12 3 4 5 6 7 
not at all a great deal 

24. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

25. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

26. In the past seven days, how much have people in 
your personal life treated you as though they did 
not respect or value you as a person? 

12 3 4 5 6 7 
not at all a great deal 

27. How much did these occurrences bother you, 

including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 



93 



28. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

29. In the past seven days, how much have people in 

your personal life broken a promise to help you or 
do something for you? 

12 3 4 5 6 7 
not at all a great deal 

30. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

31. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 

32. In the past seven days, how much have people in 
your personal life hurt your feelings? 

12 3 4 5 6 7 
not at all a great deal 

33. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

34. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 



94 



35. In the past seven days, how much have people in 
your personal life taken advantage of you? 

12 3 4 5 6 7 
not at all a great deal 

36. How much did these occurrences bother you, 
including your emotions, your thoughts, and your 
behavior? 

12 3 4 5 6 7 
no impact a great deal 

of impact 

37. How would you explain why these interactions 
occurred? 

12 3 4 5 6 7 
something to something to do 

do with me with others or 

the situation 



95 



COMQ 



Below you will find a list of specific behaviors or 
feelings. Imagine yourself in each situation, and 
using the rating scale given below, mark the most 
appropriate number on the answer sheet provided. 



1 


2 


3 


4 


not at all 


a little 


guite a lot 


a great deal 


like me 


like me 


like me 


like me 



1. Start a conversation with someone I 
don't know well, but would like to 

know better. 12 3 4 

2 . Be confident in my ability to make 
friends, even in a situation where I 

know few people. 12 3 4 

3. Be able to mix well in a group. 12 3 4 

4 . Feel uncomfortable looking at other 

people directly. 12 3 4 

5. Have trouble keeping a conversation 
going when I'm just getting to know 

someone. 12 3 4 

6. Find it hard to let a person know that 
I want want to become closer friends 

with him/her. 12 3 4 

7. Enjoy social gatherings just to be 

with people. 12 3 4 

8 . Have problems getting other people 

to notice me. 12 3 4 

9. Feel confident of my social behavior. 12 3 4 

10. Seek out social encounters because I 

enjoy being with other people. 12 3 4 



96 



QRI 

The series of questions on these pages ask for general 
information about several people in your life. Each 
page asks about a different person. 

The following questions ask about . Please 

answer them on THIS sheet. 

Age: Length of time you have known this 

person : 

The first series of questions concerns your 

relationship with . Please use the scale 

provided when answering each question and mark your 
answers on the answer sheet. 

12 3 4 

Not at all A little Quite a bit Very much 



1. To what extent could you turn to this person for 
advice about problems? 

2 . How often do you have to work hard to avoid 
conflict with this person? 

3 . To what extent could you count on this person for 
help with a problem? 

4. How upset does this person sometimes make you feel? 

5. To what extent can you count on this person to give 
you honest feedback, even if you might not want to 
hear it? 

6. How much does this person like you? 

7. How much does this person make you feel guilty? 

8. How important a role do you play in this person's 
life? 

9 . How much do you have to "give in" in this 
relationship? 

10. To what extent can you count on this person to help 
you if a family member very close to you died? 

11. How much better would your life be if you no longer 
had a relationship with this person? 

12. How much does this person want you to change? 

13. To what extent could you count on this person for 
help if you were in a crisis situation, even if 
he/she had to go out of his/her way to help you? 

14. How much more do you give than you get from this 
relationship? 

15. How upset do you think this person would be if he 
or she could not continue the relationship with 
you? 

16. How positive a role does this person play in your 
life? 

17. How significant is this relationship in your life? 



97 



18 . To what extent can you trust this person not to 
hurt your feelings? 

19. How confident are you that this person really cares 
about you? 

20. How close will your relationship be with this 
person in 10 years? 

21. How much would you miss this person if the two of 
you could not see or talk with each other for a 
month? 

22. How often do problems that occur in this 
relationship get resolved? 

23. How critical of you is this person? 

24. If you could have only a very small number of 
social relationships, how much would you want 
contact with this person to be among them? 

25. If you wanted to go out and do something this 
evening, how confident are you that this person 
would be willing to do something with you? 

26. How responsible do you feel for this person's well- 
being? 

27. How obligated would you feel to help this person? 

28. How much do you depend on this person? 

29. How considerate is this person of your needs? 

30. To what extent can you count on this person to 
listen to you when you are very angry at someone 
else? 

31. How much would you like this person to change? 

32. How angry does this person make you feel? 

33. If this person could afford to, how confident are 
you that he/she would loan you money if you needed 
it? 

34. How much do you argue with this person? 

35. If you were sick, how confident are you that this 
person would help you until you got better? 

36. How upset would you be if your relationship with 
this person were completely ended? 

37. To what extent can you really count on this person 
to distract you from your worries when you feel 
under stress? 

38. How often does this person make you feel angry? 

39. How often does this person try to control or 
influence your life? 

40. How much do you enjoy spending time with this 
person? 

41. Regardless of how positive this relationship might 
be for you, to what extent is it also negative, for 
example, a source of conflict (arguments, 
misunderstandings, guilt)? 

42. If you had an important personal problem tomorrow, 
how confident are you that this person would help 
you? 

43. Currently, how satisfied are you with this 
relationship? 

44. How much does this person depend on you? 



APPENDIX B 
DYADIC EFFECTIVENESS SCALE 



Dyadic Effectiveness Scale 

1. If you had a somewhat dangerous or difficult 
assignment, to what degree would you like to have 
this person as your partner in carrying it out? 

2 . To what degree do you think this person would be a 
good friend? 

3. To what extent would you like to have this person 
as your leader or supervisor? 

4. If you had a personal problem, to what degree could 
you count on this person to help you solve it? 

5. To what degree do you feel this person would be a 
team player, someone who would contribute to 
achieving group goals? 

6. To what degree do you feel this person is 
considerate? 

7. To what degree would you expect this person to have 
good judgment? 

8. To what degree do you think this person is 
interested in what other people have to say? 

9. To what degree do you see this person as being 
successful in social relationships? 

10. To what degree does this person make a good 
impression physically? 



1 = Not at all 

2 = Very slightly 

3 = Slightly 

4 = Moderately 

5 = Quite a lot 

6 = Very, very much 



Leadership subscale = Items 1, 3, 4, 5, and 7 
Consideration subscale = Items 2, 6, and 8 
Attractiveness subscale = Items 9 and 10 



99 






APPENDIX C 
VIDEOTAPED INTERACTION 



Instructions given to female dyads: 

"Now I would like for you both to imagine that you 
are roommates and that you have a third female 
roommate. You have been living together for about a 
month, and have found that your third roommate is very 
difficult to get along with. What I want you to do now 
is to talk about how you might improve your living 
situation with regard to this difficult and annoying 
roommate. You have to continue living with her until 
the end of the semester. You'll have five minutes to 
discuss this issue. Please continue to talk about it 
until I tell you to stop. Do you have any questions?" 



Instructions given to observer raters: 

"You will be watching a five-minute interaction 
between two female roommates discussing how they might 
deal with a third female roommate who is difficult to 
get along with. What I want you to do is watch the 
entire video and then rate each subject in the video 
using this measure [Dyadic Effectiveness Scale]. There 
are 10 questions which you should rate using this scale 
from 1 (not at all) to 6 (very/ very much) . Please 
answer all 10 guestions for one subject in each pair 
before going on to rate the second subject. 

To indicate which subject you are rating, label 
the scale for each subject using the code on the 
videotape and indicate if the subject was on the right 
or the left." 



101 



102 



Summary of training instructions given to confederate: 

The female confederate who participated in all 
interactions was a first-year graduate student in 
clinical psychology who was introduced to subjects as 
simply another participant in the study. Prior to the 
beginning of the study, the confederate and the author 
generated a number of standard responses to possible 
subject verbalizations. These included guestions or 
comments such as "What do you think we should do? 11 , 
"How do you think she • d respond to that? , " "We could 
try that , " etc . The confederate was instructed to 
interact with each subject in as similar a manner as 
possible, and practiced with several individuals before 
the study began. She attempted to remain fairly 
passive, while contributing enough to the interaction 
that her status as a confederate would remain unknown. 
This was accomplished by using technigues such as 
reflection and paraphrasing rather than volunteering 
her own solutions to the situation. In addition, the 
confederate was instructed to refrain from expressing 
value judgments on the subject's opinions, and in 
general, to allow each subject as much opportunity as 
possible to demonstrate her social skills (or lack 
thereof) . 



REFERENCES 

Abbey, A., Abramis, D. J. , & Caplan, R.D. (1985). 

Effects of different sources of social support and 
conflict on emotional well-being. Basic and Applied 
Social Psychology . 6(2), 111-129. 

Abraham, S.F., & Beumont, P.J. (1982). How patients 
describe bulimia or binge eating. Psychological 
Medicine , 12, 625-635. 

American Psychiatric Association. (1980) . Diagnostic 
and statistical manual of mental disorders (3rd 
ed. ) . Washington, DC: Author. 

American Psychiatric Association. (1987) . Diagnostic 
and statistical manual of mental disorders (3rd ed.- 
revised) . Washington, DC: Author. 

Baird, P., & Sights, J.R. (1986). Low self-esteem as a 
treatment issue in the psychotherapy of anorexia 
nervosa and bulimia. Journal of Counseling and 
Development . 64 . 449-451. 

Barrera, M. (1981) . Social support in the adjustment of 
pregnant adolescents: Assessment issues. In B.H. 
Gottlieb (Ed.), Social networks and social support . 
Beverly Hills: Sage. 

Barrera, M. (1986) . Distinctions between social support 
concepts, measures, and models. American Journal of 
Community Psychology . 14(4), 413-445. 

Berkman, L.F. (1985). The relationship of social 
networks and social support to morbidity and 
mortality. In S. Cohen & S.L. Syme (Eds.), Social 
support and health (pp. 241-262) . New York: 
Academic Press. 

Beumont, P.J.V., George, G.C.W., & Smart, D.E. (1976). 
"Dieters" and "vomiters and purgers" in anorexia 
nervosa. Psychological Medicine . 6, 617-622. 

Billings, A.G., & Moos, R.H. (1981). The role of coping 
measures and social resources in attenuating the 
stress of life events. Journal of Behavioral 
Medicine . 6, 139-157. 



103 



104 



Boskind-Lodahl , M. (1976). Cinderella's stepsisters: A 
feminist perspective on anorexia nervosa and 
bulimia. Signs: Journal of Women in Culture and 
Society , 2, 342-356. 

Boskind-Lodahl, M. , & White, W.C. (1978). The 

definition and treatment of bulimarexia in college 
women — A pilot study. Journal of American College 
Health Association . 27 , 84-97. 

Boskind-White, M. , & White, W. (1983). Bulimarexia: 
The binge-purge syndrome . New York: W.W. Norton. 

Brenner, G. , Norvell, N. , & Limacher, M. (in press). 
Negative social interactions: Differential 
importance of core and peripheral social network 
members. Journal of Community and School Psychology . 

Brotman, A.W., Herzog, D.B., & Woods, S.W. (1984). 
Antidepressant treatment of bulimia: The 
relationship between binging and depressive 
symptomatology. Journal of Clinical Psychiatry , 142 , 
495-496. 

Bruch, H. (1973) . Eating disorders: Obesity, anorexia 
nervosa, and the person within . New York: Basic. 

Casper, R.C., Eckert, E.D., Halmi, K.A. , Goldberg, 

S.C., & Davis, J.M. (1980). Bulimia: Its incidence 
and clinical importance in patients with anorexia 
nervosa. Archives of General Psychiatry , 37 . 1030- 
1035. 

Cattanach, L. , & Rodin, J. (1988). Psychosocial 
components of the stress process in bulimia. 
International Journal of Eating Disorders . 7(1) , 75- 
88. 

Cohen, S. (1988). Psychosocial models of the role of 
social support in the etiology of physical disease. 
Health Psychology . 7(3), 269-297. 

Cohen, S., & Hoberman, H.M. (1983). Positive events and 
social supports as buffers of life change stress. 
Journal of Applied Social Psychology . 13., 423-439. 

Cohen, S., Mermelstein, R. , Kamarck, T., & Hoberman, 
H.M. (1985) . Measuring the functional components of 
support. In 1.6. Sarason & B.R. Sarason (Eds.), 
Social support: Theory, research, and applications 
(pp. 73-94). Dordrecht, The Netherlands: Martinus- 
Nijhoff. 



105 



Cohen, S., Sherrod, D.R. , & Clark, M.S. (1986). Social 
skills and the stress-protective role of social 
support . Journal of Personality and Social 
Psychology , 50(5), 963-973. 

Cohen, S., & Syme, L. (1985). Issues in the study and 

application of social support. In S. Cohen & L. Syme 

(Eds.), Social support and health (pp. 3-22). 
Orlando, FL: Academic Press. 

Cohen, S., & Wills, T.A. (1985). Stress, social 

support, and the buffering hypothesis. Psychological 
Bulletin . 98/ 310-357. 

Cooper, P.J., Charnock, D.J., & Taylor, M.J. (1987). 
The prevalence of bulimia nervosa: A replication 
study. British Journal of Psychiatry , 151, 684-686. 

Coyne, J.C., Aldwin, C, & Lazarus, R.S. (1981). 

Depression and coping in stressful episodes. Journal 
of Abnormal Psychology . 90 . 439-447. 

Cutrona, C.E. (1986) . Objective determinants of 

perceived social support. Journal of Personality and 
Social Psychology . 50(2), 349-355. 

Derogatis, L.R., Rickels, K. , & Rock, A.F. (1976). The 
SCL-90 and the MMPI: A step in the validation of a 
new self -report scale. British Journal of 
Psychiatry . 128 , 280-289. 

Drewnowski, A., Yee, D.K., & Krahn, D.D. (1988). 

Bulimia in college women: Incidence and recovery 
rates. American Journal of Psychiatry . 145 (6) , 753- 
755. 

Dunkel-Schetter, C. , Folkman, S., & Lazarus, R.S. 
(1987) . Correlates of social support receipt. 
Journal of Personality and Social Psychology , 53 (1) , 

71-80. 

Dunn, P.K., & Ondercin, P. (1981). Personality 

variables related to compulsive eating in college 
women. Journal of Clinical Psychology . 1, 43-49. 

Eckenrode, J. (1983) . The mobilization of social 
supports: Some individual constraints. American 
Journal of Community Psychology . 11(5), 509-528. 

Eckenrode, J., & Gore, S. (1981). Stressful events and 
social supports: The significance of context. In 
B.H. Gottlieb (Ed.), Social networks and social 
support . Beverly Hills: Sage. 



106 



Elliot, G.R., & Eisdorfer, C. (Eds.) (1982). Stress and 
human health: Analysis and implications of 

research. New York: Springer. 

Faschinghauer, T.R. (1974) . A 166-item written short- 
form of the group MMPI: The FAM. Journal of 
Clinical and Community Psychology , 42:645-656. 

Fairburn, C. (1980) . Self-induced vomiting. Journal of 
Psychosomatic Research . 24, 193-197. 

Fairburn, C. (1981) . A cognitive-behavioral approach to 
the treatment of bulimia. Psychological Medicine . 
111 . 707-711. 

Fiore, J., Becker, J., & Coppel, D.B. (1983). Social 
network interactions: A buffer or a stress. 
American Journal of Community Psychology . 11(4) , 
423-439. 

Gandour, M.J. (1984) . Bulimia: Clinical description, 
assessment, etiology, and treatment. International 
Journal of Eating Disorders , 3, 3-37. 

Garfinkel, P.E., Garner, D.M. , & Goldbloom, D.S. 
(1987) . Eating Disorders: Implications for the 
1990's. Canadian Journal of Psychiatry . 32 . 626-631. 

Garner, D.M. , Garfinkel, P.E., Schwartz, D. , & 
Thompson, M. (1980) . Cultural expectation of 
thinness in women. Psychological Reports , 47 , 483- 
491. 

Garner, D.M. , Garfinkel, P.E., & Olmsted, M. (1983). An 
overview of sociocultural factors in the development 
of anorexia nervosa. In Anorexia nervosa: Recent 
developments in research . New York: Liss. 

Garner, D.M. , & Olmsted, M.P. (1984). Manual for Eating 
Disorder Inventory (EDI) . Odessa, FL: Psychological 
Assessment Resources, Inc. 

Gillen, B. (1981). Physical attractiveness: A 

determinant of two types of goodness. Personality 
and Social Psychology Bulletin . 7, 277-281. 

Glassman, A.H., & Walsh, B.T. (1983). Link between 

bulimia and depression unclear. Journal of Clinical 
Psychopharmacology . 3, 203. 



107 



Grissett, N., & Norvell, N. (1987, November). 

Psychophysiological and self-report responses of 
bulimic and normal women . Presented at the annual 
meeting of the Association for the Advancement of 
Behavior Therapy, Boston, Massachusetts. 

Goode, E.T. (1985) . Medical aspects of the bulimic 
syndrome and bulimarexia. Transactional Analysis 
Journal, 15, 4-11. 

Goodsitt, A. (1984) . Self -psychology and the treatment 
of anorexia nervosa. In D.M. Garner and P.E. 
Garfinkel, eds. A handbook of psychotherapy for 
anorexia nervosa and bulimia . New York: Guilford. 

Gore, S. (1978). The effect of social support in 

moderating the health conseguences of unemployment. 
Journal of Health and Social Behavior , 19 . 157-165. 

Gottlieb, B.H. (1984, July) . Social support and the 
study of personal relationships . Paper presented at 
the Second International Conference on Personal 
Relationships, Madison, Wisconsin. 

Gwirtsman, H.E., Roy-Byrne, H.E., & Yager, J. (1983). 
Neuroendocrine abnormalities in bulimia. American 
Journal of Psychiatry . 140 . 559-563. 

Hall, A., & Wellman, B. (1985). Social networks and 

social support. In S. Cohen & L. Syme (Eds.), Social 
support and health (pp. 23-41) . New York: Academic 
Press. 

Halmi, K.A., Falk, J.R., & Schwartz, E. (1981). Binge 
eating and vomiting: A survey of a college 
population. Psychological Medicine . 11 , 697-706. 

Hart, K.J., & Ollendick, T.H. (1985) Prevalence of 
bulimia in working and university women. American 
Journal of Psychiatry . 142 . 851-854. 

Hatsukami, D., Owen, P., Pyle, R. , Mitchell, J. (1982). 
Similarities and differences on the MMPI between 
women with bulimia and women with alcohol or drug 
abuse problems. Addictive Behaviors . 7, 435-439. 

Hawkins, R.C., & Clement, P.F. (1980). Development and 
construct validation of a self-report measure of 
binge-eating tendencies. Addictive Behaviors , 5, 
219-226. 



108 



Heilbrun, A.B., Jr., & Bloomfield, D.L. (1986). 

Cognitive differences between bulimic and anorexic 
females: Self-control deficits in bulimia. 
International Journal of Eating Disorders , 5, 209- 
222. 

Henderson, S., Duncan- Jones , P., McAuley, H. , & 

Ritchie, K. (1978). The patient's primary group. 
British Journal of Psychiatry , 132 . 74-86. 

Herzog, D.B. (1982) . Bulimia: The secretive syndrome. 
Psychosomatics , 23 , 481-487. 

Herzog, D.B., Keller, M.B., Lavori, P.W. , & Ott, I.L. 
(1987) . Social impairment in bulimia. International 
Journal of Eating Disorders . 6(6), 741-747. 

Herzog, D.B., Norman, D.K., Rigotti, N.A. , & Pepose, M. 
(1986) . Frequency of bulimic behaviors and 
associated social maladjustment in female graduate 
students. Journal of Psychiatry Research , 20(4) , 
355-361. 

House, J.S. (1981) . Work stress and social support . 
Reading, MA: Addison-Wesley. 

Hudson, J.I., Laffer, P.S., & Pope, H.G. (1982). 

Bulimia related to affective disorder by family and 
response to the dexamethasone suppression test. 
American Journal of Psychiatry , 139 (5) , 685-687. 

Hudson, J.I., Pope, H.G. , Jonas, J.M. , & Yergelun-Todd, 
D. (1983) . Family history study of anorexia nervosa 
and bulimia. British Journal of Psychiatry , 142 , 
133-138. 

Humphrey, L.L., Apple, R. , & Kirschenbaum, D.S. (1985). 
Differentiating bulimic-anorexic from normal 
families using interpersonal and behavioral 
observational systems. Journal of Consulting and 
Clinical Psychology . 54(2). 190-195. 

Johnson, C. & Berndt, D.J. (1983) . Preliminary 
investigation of bulimia and life adjustment. 
American Journal of Psychiatry . 140(6), 774-777. 

Johnson, C, & Flach, A. (1985). Family characteristics 
of 105 patients with bulimia. American Journal of 
Psychiatry . 142(11), 1321-1324. 

Johnson, C. , & Larson, R. (1982). Bulimia: An analysis 
of moods and behavior. Psychosomatic Medicine . 
44(4), 333-345. 



109 



Johnson, C. , & Maddi, K.L. (1986). The etiology of 
bulimia: Biopsychosocial perspectives. Annals of 
Adolescent Psychiatry , 13, 253-273. 

Johnson, C. , Stuckey, M.K., Lewis, L.D., & Schwartz, D. 
(1982). Bulimia: A descriptive survey of 316 cases. 
International Journal of Eating Disorders , 2(1) , 3- 
16. 

Jung, J. (1984) . Social support and its relation to 
health: A critical evaluation. Basic and Applied 
Social Psychology , 5(2), 143-169. 

Katzman, M.A. , & Wolchik, S.A. (1984). Bulimia and 
binge eating in college women: A comparison of 
personality and behavioral characteristics. Journal 
of Consulting and Clinical Psychology , 52 . 423-428. 

Katzman, M.A. , & Wolchik, S.A. (1985). Bulimia, binge 
eating, and depression: A study of coping 
strategies . Presented at the annual meeting of the 
American Psychological Association, Los Angeles, 
California. 

Kessler, R.C., & McLeod, J.D. (1985). Social support 
and mental health in community samples. In S. Cohen 
& S.L. Syme (Eds.), Social support and health (pp. 
219-240) . New York: Academic Press. 

Kobasa, S.C., & Pucetti, M.C. (1983). Personality and 
social resources in stress resistance. Journal of 
Personality and Social Psychology , 45 , 839-850. 

Kohut, H. (1971) . The analysis of the self . New York: 
International Universities Press. 

Lazarus, R.S. (1966) . Psychological stress and the 
coping process . New York: McGraw-Hill. 

Lazarus, R.S., & Launier, R. (1978). Stress-related 
transactions between person and environment. In L. 
Pervin and M. Lewis (Eds.), Perspectives in 
interactional psychology (pp. 287-327) . New York: 
Plenum. 

Lefcourt, H.M., Martin, R.A. , & Saleh, W.E. (1984). 
Locus of control and social support: Interactive 
moderators of stress. Journal of Personality and 
Social Psychology . 47 , 378-389. 

Lehman, A., & Rodin, J. (1986). Styles of self- 
nurturance and disordered eating . Unpublished 
manuscript, Yale University. 



110 



Lewis, L.D., & Johnson, C. (1985). A comparison of sex 
role orientation betwen women with bulimia and 
normal controls. International Journal of Eating 
Disorders , 247-257. 

Mitchell, J.E., & Eckert, E.D. (1987). Scope and 
significance of eating disorders. Journal of 
Consulting and Clinical Psychology , 55(5), 628-634. 

Norman, D.K, & Herzog, D.B. (1984). Persistent social 
maladjustment in bulimia: A 1-year follow-up. 
American Journal of Psychiatry . 141(3), 444-446. 

Ordman, A.M., & Kirschenbaum, D.S. (1984). Bulimia: 
Assessment of eating, psychological adjustment, and 
familial characteristics. International Journal of 
Eating Disorders , 5, 865-878. 

Pagel, M.D., Erdly, W.W. , & Becker, J. (1987). Social 
networks: We get by with (and in spite of) a little 
help from our friends. Journal of Personality and 
Social Psychology . 53(4), 793-804. 

Palmer, R.L. (1979). The dietary chaos syndrome: A 
useful new term? British Journal of Medical 
Psychology , 52 , 187-190. 

Pearlin, L.I., Menaghan, E.G., Lieberman, M.A. , & 

Mullan, J.T. (1981) . The stress process. Journal of 
Health and Social Behavior , 22, 337-356. 

Pearlin, L.I., & Schooler, C. (1978). The structure of 
coping. Journal of Health and Social Behavior . 19 . 
2-21. 

Pierce, G.R., Sarason, I.G., & Sarason, B.R. (1988). 
Quality of relationships and social support as 
personality characteristics . Paper presented at the 
annual meeting of the American Psychological 
Association, Atlanta, Georgia. 

Pierce, G.R., Sarason, B.R., & Sarason, I.G. (1989). 
Quality of relationships and social support: 
Empirical and conceptual distinctions . Paper 
presented at the annual meeting of the American 
Psychological Association, New Orleans, Louisiana. 

Pope, H.G., & Hudson, J.I. (1982). Treatment of bulimia 
with antidepressants. Psychopharmacology . 78 . 176- 
179. 



Ill 



Pope, H.G., Hudson, J.I., Jonas, J.M., & Yergelun-Todd, 
D. (1983) . Bulimia treated with imipramine: A 
placebo-controlled, double-blind study. American 
Journal of Psychiatry , 140 , 554-558. 

Procidano, M.E., & Heller, K. (1983). Measures of 
perceived social support from friends and from 
family: Three validation studies. American Journal 
of Community Psychology , 11 . 1-24. 

Pyle, R.L., Mitchell, J.E., & Eckert, E.D. (1981). 

Bulimia: A report of 34 cases. Journal of Clinical 
Psychiatry , 42 , 60-84. 

Pyle, R.L., Halvorson, P. A. , Neuman, P. A. , & Mitchell, 
J.E. (1986) . The increasing prevalence of bulimia in 
freshman college students. International Journal of 

Eating Disorders , 3, 45-51. 

Rau, J.H., & Green, R. (1975). Compulsive eating: A 
neuropsychologic approach to certain eating 
disorders. Comprehensive Psychiatry . 16 . 223-231. 

Riebel, L.K. (1989) . Communication skills for eating- 
disordered clients. Psychotherapy , 26(1), 69-74. 

Riley, D. , & Eckenrode, J. (1986). Social ties: 

Subgroup differences in costs and benefits. Journal 
of Personality and Social Psychology , 51, 770-778. 

Rook, K.S. (1984) . The negative side of social 

interaction: Impact on psychological well-being. 
Journal of Personality and Social Psychology . 46(5) , 
1097-1108. 

Rosenberg, M. (1965) . Society and the adolescent self- 
image . Princeton, NJ: Princeton University Press. 

Russell, G. (1979) . Bulimia nervosa: An ominous 

variant of anorexia nervosa. Psychological Medicine , 
9, 429-448. 

Sabine, E.J., Yonace, A, Farrington, A. J. , Baratt, 
K.H. , & Wakeling, A. (1983). Bulimia nervosa: A 
placebo-controlled, double-blind therapeutic trial 
of mianserin. British Journal of Clinical 
Pharmacology , 15 , 195S-202S. 

Sarason, I.G., Levine, H.M. , Basham, R.B., & Sarason, 
B.R. (1983) . Assessing social support: The social 
support questionnaire. Journal of Personality and 
Social Psychology . 44 , 127-130. 



112 



Sarason, I.G., Sarason, B.R. , Hacker, T.A. , & Basham, 
R.B. (1985). Concomitants of social support: Social 
skills, physical attractiveness, and gender. Journal 
of Personality and Social Psychology . 49 , 469-480. 

Sarason, 1.6. , Sarason, B.R., & Shearin, E.N. (1986). 
Social support as an individual difference variable: 
Its stability, origins, and relational aspects. 
Journal of Personality and Social Psychology , 50 , 
845-855. 

Sarason, B.R., Shearin, E.N., Pierce, G.R. , & Sarason, 
1.6. (1987). Interrelations of social support 
measures: Theoretical and practical implications. 
Journal of Personality and Social Psychology . 52.(4) , 
813-832. 

Schneider, J. A., & Agras, W.S. (1985). A cognitive 
behavioral group treatment of bulimia. British 
Journal of Psychiatry , 146, 66-69. 

Shatford, L.A. , & Evans, D.R. (1986). Bulimia as a 
manifestation of the stress process: A LISREL 
causal modeling analyis. International Journal of 
Eating Disorders , 5(3), 451-473. 

Shinn, M. , Lehmann, S., & Wong, N.W. (1984). Social 
interaction and social support. Journal of Social 
Issues . 40(4), 55-76. 

Shisslak, CM., Crago, M. , Neal, M.E., & Swain, B. 
(1987) . Primary prevention of eating disorders. 
Journal of Consulting and Clinical Psychology , 
55(5), 660-667. 

Silberfeld, M. (1978) . Psychological symptoms and 
social suppports. Social Psychiatry , 13 , 11-17. 

Silberstein, L.R., Striegel-Moore, R.H., & Rodin, J. 
(1987). Feeling fat: A woman's shame. In H.B. Lewis 
(Ed.), The role of shame in symptom formation . 
Hillsdale, NJ: Erlbaum. 

Slater, S.J. (March, 1988) . Eating disorders and social 
support . Presented at the Southeastern Psychological 
Association, New Orleans, Louisiana. 

Slater, S.J., Grissett, N.I., & Norvell, N.K. (August, 
1988) . Social support and maladjustment in bulimic 
and normal women . Presented at the annual meeting 
of the American Psychological Association. 



113 



Smith, M.C., & Thelen, M.H. (1984). Development and 
validation of a test for bulimia. Journal of 
Consulting and Clinical Psychology . 52 , 863-872. 

Stein, D.M. , and Laakso, W. (1988). Bulimia: A 

historical perspective. International Journal of 
Eating Disorders . 7(2), 201-210. 

Steiner-Adair, K. (1986) . The body politic: Normal 

female adolescent development and the development of 
eating disorders. Journal of the American Academy of 
Psychoanalysis . 14 , 95-114. 

Striegel-Moore, R.H., Silberstein, L.R., & Rodin, J. 
(1986) . Toward an understanding of risk factors for 
bulimia. American Psychologist , 41, 246-263. 

Stunkard, A.J. (1959) . Eating patterns of obese 
persons. Psychiatric Quarterly . 33 , 284-292. 

Thibaut, J., & Kelley, H.H. (1959). The social 
psychology of groups . New York: Wiley. 

Thoits, P. A. (1982). Conceptual, methodological, and 
theoretical problems in studying social support as a 
buffer against life stress. Journal of Health and 
Social Behavior , 23 , 145-155. 

Thoits, P. A. (1986) . Social support as coping 

assistance. Journal of Consulting and Clinical 
Psychology . 54(4), 416-423. 

Timko, C, Striegel-Moore, R.H., Silberstein, L.R. , & 
Rodin, J. (1987) . Femininity/masculinity and 
disordered eating in women: How are they related? 
International Journal of Eating Disorders , 6(6) , 
701-712. 

Tolsdorf, C.C. (1976). Social networks, support, and 
coping: An exploratory study. Family Process , 15, 
407-418. 

Van Buren, D.J., & Williamson, D.A. (1988). Marital 
relationships and conflict resolution skills of 
bul imics . International Journal of Eating Disorders , 
7(6), 735-741). 

Vinokur, A., Schul, Y., & Caplan, R.D. (1987). 
Determinants of perceived social support: 
Interpersonal transactions, personal outlook, and 
transient affective states. Journal of Personality 
and Social Psychology . 53(6), 1137-1145. 



114 



Wallston, B.S., Magna, S.W., DeVellis, B.M. , & 

DeVellis, R.F. (1983) . Social support and physical 
health. Health Psychology , 4, 367-391. 

Walsh, B.T., Stewart, J.M., Wright, L. , Harrison, W. , 
Roose, S.P., & Glassman, A.H. (1982). Treatment of 
bulimia with monoamine oxidase inhibitors. American 
Journal of Psychiatry , 139 . 1629-1630. 

Weissman, M.M., Prusoff, B.A. , & Thompson, W.D. (1976). 
Social maladjustment by self -report. Archives of 
General Psychiatry , 33 , 1111-1115. 

Wilcox, B.L. (1981). Social suupport, life stress, and 
psychological adjustment: A test of the buffering 
hypothesis. American Journal of Community 
Psychology . 9, 371-386. 

Williamson, D.A. , Keller, M.L., Davis, C.J., Ruggiero, 
L. , & Blouin, D.C. (1985). Psychopathology of eating 
disorders: A controlled comparison of bulimic, 
obese, and normal subjects. Journal of Consulting 
and Clinical Psychology , 53 , 161-166. 



BIOGRAPHICAL SKETCH 

Nadine Ines Grissett was born on September 26, 
1964, in St. Croix, U.S. Virgin Islands, to Charles 
Grissett and Lydia Carlson. In 1985, Ms. Grissett 
obtained a Bachelor of Science degree in psychology 
from Stetson University in DeLand, Florida. After 
working briefly at an inpatient psychiatric facility, 
Ms. Grissett entered the graduate clinical psychology 
program at the University of Florida. Here she minored 
in medical psychology and obtained a Master of Science 
degree in August, 1987. At present, Ms. Grissett and 
her husband live in the Chicago area, where she is 
employed as program coordinator and health psychology 
counselor in the Eating Disorders Clinic at 
Northwestern Memorial Hospital. Following completion 
of her doctorate degree in clinical psychology, Ms. 
Grissett plans to pursue a career in research and 
clinical practice. 



115 



I certify that I have read this study and that in 
my opinion it conforms to acceptable standards of 
scholarly presentation and is fully adequate, in scope 
and quality, as a dissertation for the degree of 
Doctor of Philosophy. 



Nancy l^'Norvell, Ph.D., Chair 
Assistant Professor of 
Clinical and Health Psychology 



I certify that I have read this study and that in 
my opinion it conforms to acceptable standards of 
scholarly presentation and is fully adequate, in scope 
and quality, as a dissertation for the degree of 
Doctor of Philosophy. 



Vftr 




Jmes Johnson, Ph.D. 
fofessor of Clinical and 
lealth Psychology 



I certify that I have read this study and that in 
my opinion it conforms to acceptable standards of 
scholarly presentation and is fully adequate, in scope 
and quality, as a dissertation for the degree of 
Doctor of Philosophy. 




ithony Greene, Ph.D. 
Assistant Professor of 
Clinical and Health Psychology 



I certify that I have read this study and that in 
my opinion it conforms to acceptable standards of 
scholarly presentation and is fully adequate, in scope 
and quality, as a dissertation for the degree of 
Doctor of Philosophy. 



Jacquelin Goldman, Ph.D. 
Professor of Clinical and 
Health Psychology 



I certify that I have read this study and that in 
my opinion it conforms to acceptable standards of 
scholarly presentation and is fully adequate, in scope 
and quality, as a dissertation for the degree of 
Doctor of Philosophy. 



/ 




John Kuldau, M.D. 
Professor of Psychiatry 



This dissertation was submitted to the Graduate 
Faculty of the College of Health Related Professions 
and to the Graduate School and was accepted as partial 
fulfillment of the requirements for the degree of 
Doctor of Philosophy. 

May 1991 U>1vJ)tC. \uJo3(lu^v>r 

Dean, College of Health 
Related Professions 



Dean, Graduate School